Editor's Choice - Risk of Rupture and All Cause Mortality of Abdominal Aortic Ectasia: A Systematic Review and Meta-Analysis.

OBJECTIVE: To clarify the natural history of abdominal aortic ectasia (AAE) measuring 25 - 29 mm in maximum diameter, and to determine the optimal follow up based on the growth, risk of rupture, and overall mortality of AAE. DATA SOURCES: MEDLINE, Web of Science Core Collection, and Google Scholar. REVIEW METHODS: This was a systematic review and meta-analysis of AAE in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. MEDLINE, Web of Science Core Collection, and Google Scholar were searched, with the help of a health sciences librarian, up to 11 August 2021. Studies with longitudinal outcomes of AAE (prevalence, annual growth rate, aneurysmal enlargement, rupture, aneurysm related death, and all cause mortality) were included. Meta-analyses were conducted with a random effects model RESULTS: Twelve studies describing a total of 8 369 patients were eligible. The prevalence at population based settings was 3.2% (95% confidence interval [CI] 2.4 - 4.0); annual growth rate was 0.82 mm/year (95% CI 0.20 - 1.45). The estimated risks of aortic diameters exceeding 30 mm and 55 mm in five years were 45.0% (95% CI 28.5 - 61.5) and 0.3% (95% CI 0 - 0.6) respectively, while those beyond five years were 70.2% (95% CI 46.9 - 93.6) and 5.2% (95% CI 2.2 - 8.2). The rates of rupture and aneurysm related death were minimal until five years (0.1% and 0.1%, respectively) and beyond (0.4% and 0.2%, respectively). Overall mortality was 7.5% (95% CI 3.9 - 11.0) and 17.3% (95% CI 9.5 - 25.1) up to and beyond five years. Overall mortality from three studies showed no statistical difference between AAE and aneurysms (hazard ratio 0.62, 95% CI 0.32 - 1.21; p = .16). Cancer (35.0%) and cardiovascular diseases (31.9%) were major causes of death. CONCLUSION: AAE carries minimal risk of aneurysm related lethal events during the first five years, but a similar overall mortality risk as abdominal aortic aneurysm. Cancer and cardiovascular diseases are leading causes of death in patients with AAE.

Predicting Postoperative Destination Through Preoperative Evaluation in Elective Open Aortic Aneurysm Repair.

BACKGROUND: There are limited data guiding preoperative counseling on the need for discharge to facility after elective open abdominal aortic aneurysm repair (OAR). This study aims to determine the preoperative predictors for nonhome discharge (NHD) following OAR. MATERIALS AND METHODS: The National Surgical Quality Improvement Program Vascular Procedure Targeted database was queried for elective OAR, 2011-2015. The primary endpoint was NHD. Complex surgery was defined as high operative time. Multivariable logistic regression identified preoperative factors predictive of NHD. RESULTS: Overall 510 patients were included; 87 (17.1%) required NHD. Baseline characteristics differed: NHD were more frequently female, partially dependent, older, had history of chronic obstructive pulmonary disease, bleeding disorder, and anemia. After risk adjustment, age≥70 y (odds ratio [OR]: 12.48, confidence interval [CI]: 2.89-53.99; P = 0.001), partial dependence (OR: 8.17, CI: 1.39-47.84; P = 0.02), female sex (OR: 1.88, CI: 1.10-3.20; P = 0.02), history of bleeding disorder (OR: 2.65, CI: 1.14-6.15; P = 0.02), and high operative time (OR: 1.84, CI: 1.03-3.26; P = 0.04) were independent predictors of NHD. On unadjusted analysis, NHD was not associated with increased major postdischarge complications (OR: 1.52, CI: 0.48-4.78; P = 0.47 P = 0.47) or unplanned readmission (OR: 0.74, CI: 0.25-2.16; P = 0.58) CONCLUSIONS: NHD following OAR can be predicted using preoperative factors including age, functional status, sex, history of bleeding disorder, and complex repair. NHD was not associated with more major postdischarge complications or unplanned readmission. A better understanding of patients at risk for NHD will allow for better preoperative counseling and will help to set appropriate expectations.

Timing of Carotid Endarterectomy After Stroke: Retrospective Review of Prospectively Collected National Database.

OBJECTIVE: Our objective was to identify the postoperative risk associated with different timing intervals of repair. BACKGROUND: Timing of carotid intervention in poststroke patients is widely debated with the scales balanced between increased periprocedural risk and recurrent neurologic event. National database reviews show increased risk to patients treated within the first 2 days of a neurologic event compared to those treated after 6 days. METHODS: Utilizing Vascular Quality Initiative data, all carotid interventions performed on stroke patients between the years 2012 and 2017 were queried. Patients were then stratified based on the timing of surgery from their stroke (<48 hours, 3-7 days, 8-14 days, >15 days). Major outcomes included postoperative stroke, death, and myocardial infarction. RESULTS: A total of 8404 patients were included being predominantly men (5281, 62.8%), with an average age of 69 (±10). Patients treated at greater than 8 days showed significantly less risk of postoperative combined stroke/death and postoperative stroke. There were no significant differences in postoperative stroke or death between the 8 to 14 and greater than 15 days groups.Multivariate regression analysis showed that delayed timing of surgery between 3 and 7 days was protective for postoperative stroke/death (P = 0.003) and any postoperative complication (P = 0.028). Delaying surgery to more than 8 days after stroke was protective for postoperative stroke/death (P < 0.001), postoperative stroke (P < 0.001), and any postoperative complication (P < 0.001). CONCLUSIONS: Carotid revascularization should occur no sooner than 48 hours after index stroke event. Surgeons should strive to operate between 8 and 14 days to protect against postoperative stroke/death.