WHAT THIS PAPER ADDSLate open conversions for endovascular aneurysm repair complications have increased in number over the last 20 years. They are technically challenging operations, with high post-operative mortality and morbidity rates, especially for infection and urgent operations. Morbidity rates are lower when the endograft is clamped infrarenally.Objective: The aim was to report indications, technical aspects, and outcomes of a multicentre experience of late open conversions (LOCs) after endovascular abdominal aneurysm repair (EVAR), in order to identify risk factors which may influence early morbidity and mortality rates, and long term survival. Methods: Ten vascular centres retrospectively reviewed all patients requiring LOC (!30 days from initial EVAR, undergoing total or partial endograft explantation) from 1996 to 2017. Baseline characteristics, endograft data, indications, procedural details, post-operative outcomes, and follow up data were reviewed and analysed. Results: Included patients totalled 232 (90.1% males, mean age 74.3 AE 7.9 years). The number of LOC per year significantly increased during the study period, reaching 22 in 2017 (correlation r ¼ 0.867, p < .0001). Reasons for LOC were 80.2% endoleak (186/232), 15.5% endograft infection (36/232), and 9.9% endograft thrombosis (23/232). Sixty-nine patients (29.7%) were operated on urgently; rupture was present in 18.5% (43/232). Eighty-nine patients (38.4%) underwent endovascular re-interventions prior to LOC. The proximal aortic cross clamp site was infrarenal in 40.5% (94/232), suprarenal in 25.4% (59/232), supracoeliac in 32.8% (76/232), and thoracic in 1.3% (3/232). Endograft explantation was total in 164/232 patients (70.7%), and partial in the remaining 68/232 (29.3%). The overall 30 day mortality was 11.2% (26/232). Early mortality was significantly higher for patients operated on urgently (26.1% vs. 4.9%, p < .001). Suprarenal clamping (odds ratio (OR) 2.34, 95% CI 1.12e4.88) and pre-existing renal insufficiency (OR 2.11, 95% CI 1.03e4.31) were independent risk factors for post-operative renal failure on multivariable analysis. Median follow up was 24.1 months (IQR 4.4e60.6). The estimated overall one and five year survival rates were 79.7% and 58.6%, respectively. Survival estimates were significantly lower for patients with endograft infection (83.8% vs. 59% at one year, 65.2% vs. 28.9% at five years; log rank p ¼ .005), as well as for urgent patients (87.2% vs. 62.1% at one year, 65.1% vs. 43.7% at five years; log rank p < .0001). Conclusion:The annual number of LOC increased over time. LOCs performed urgently or for endograft infection are associated with poor survival. Infrarenal aortic clamping has lower post-operative complication rates.
Spontaneous dissection of the celiac trunk is a rare and uncommon cause of acute abdominal pain. Risk factors, natural history and optimal treatment are still unclear due to the rarity of the disorder. Therapeutic strategies and follow-up procedures are based on limited observations, and the absence of guidelines warrants a patient-tailored approach. We report the case of a 50-year-old woman who presented to our emergency department for epigastric pain, nausea, and vomiting resulting from a spontaneous dissection of the celiac trunk, successfully treated endovascular technique.
Funding Acknowledgements Type of funding sources: None. Background Coronary artery disease (CAD) and aortic aneurysm (AA) share commons risk factors, such as hypertension, diabetes mellitus, hypercholesterolemia, and smoking. Cardiac assessment before aortic abdominal aneurysm (AAA) surgery is indicated for patients with symptomatic coronary artery disease (CAD). The usefulness of assessment of moderate/high-risk patients is still debated. Purpose the purpose of our study is to evaluate the safety and effectiveness of dipyridamole stress echocardiography (DSE) for the detection of CAD in patients undergoing AAA surgery with high cardiovascular risk. Methods From 2017th to 2019th 120 patients underwent surgery for aortic aneurysm (71 endovascular technique and 49 with open laparotomy). Of these, 74 asymptomatic patients with high cardiovascular risk underwent a pre-surgical contrast-enhanced dipyridamole stress echo (0,84 mg/kg over 6 minutes – protocol with LVO with sulfur hexafluoride), to exclude the presence of inducible myocardial ischemia, Mean follow-up was 6-24 months. Results Mean age was 77 years +/- 6.6, with male gender prevalent (83%). No complication during DSE occurred; mean SCORE risk was 9.8% +/- 2.3%, with 63% patients with very high risk. Only 1 patient showed inducible ischemia during stress echocardiography, with evidence of significant LAD stenosis; no myocardial infarction was reported at follow-up, while 1 ischemic stroke and 1 unplanned revascularization occurred. 11% of patients died, of which 50% for Sars-Cov-2 disease and 12% due to post-surgery dissection while no cardiac deaths were found. Conclusions dipyridamole stress echo is safe in patients with surgical-class abdominal aortic aneurism; in patients with high cardiovascular risk but no symptoms reversible ischemia is rare. DSE should not be routinely performed before high-risk surgery but only in patients with cardiac symptoms. Abstract Figure. Patients Diagram
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