Objective Prior studies suggest that percutaneous access for endovascular abdominal aortic aneurysm repair (pEVAR) offers significant operative and post-operative benefits compared to femoral cutdown (cEVAR). National data on this topic, however, are limited. We compared patient selection and outcomes for elective pEVAR and cEVAR. Methods We identified all patients undergoing either pEVAR (bilateral percutaneous access whether successful or not) or cEVAR (at least one planned groin cutdown) for abdominal aortic aneurysms (AAA), from January 2011 to December 2013 in the Targeted Vascular dataset from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. Emergent cases, ruptures, cases with an iliac conduit, and cases with a preoperative wound infection were excluded. Groups were compared using chi-square test or t-test or the Mann-Whitney test where appropriate. Results 4112 patients undergoing elective EVAR were identified; 3004 cEVAR (73%) and 1108 pEVAR (27%). Of all EVAR patients 26% had bilateral percutaneous access, 1.0% had attempted percutaneous access converted to cutdown (4% of pEVARs), while the remainder had a planned cutdown, 63.9% bilateral, and 9.1% unilateral. There were no significant differences in age, gender, aneurysm diameter or prior open abdominal surgery. Patients undergoing cEVAR were less likely to have congestive heart failure (1.5% vs. 2.4%, P=0.04) but more likely to undergo any concomitant procedure during surgery (32% vs. 26%, P<.01) than patients undergoing pEVAR. Postoperatively, pEVAR patients had shorter operative time (mean 135 vs. 152 minutes, P<.01), shorter length of stay (median 1 day vs. 2 days, P<.01), and fewer wound complications (2.1% vs. 1.0%, P=0.02). On multivariable analysis the only predictor of percutaneous access failure was performance of any concomitant procedure (OR 2.0, 95% CI 1.0–4.0, P=0.04). Conclusions Currently, 1 in 4 patients treated at Targeted Vascular NSQIP centers are getting pEVAR, which is associated with a high success rate, shorter operation time, shorter length of stay, and fewer wound complications compared to cEVAR.

There is little evidence supporting the efficacy of secondary intervention for type II endoleaks after EVAR. Although generally safe, the lack of evidence supporting the efficacy of type II endoleak treatment leads to difficulty in assessing its merits.

Introduction Bowel ischemia is a rare but devastating complication following abdominal aortic aneurysm (AAA) repair. Its rarity has prohibited extensive risk factor analysis, particularly since the widespread adoption of endovascular repair (EVAR). Therefore, the purpose of this study was to assess the incidence of postoperative bowel ischemia following AAA repair in the endovascular era, and identify risk factors for its occurrence. Methods All patients undergoing AAA repair, either intact or ruptured, in the Vascular Study Group of New England between January 2003 and November 2014 were included. We compared patients with postoperative bowel ischemia to those without, and stratified by indication (intact and ruptured) and treatment approach (open repair and EVAR). Criteria for diagnosis were endoscopic or clinical evidence of ischemia, including bloody stools in patients who died before diagnostic procedures were performed. Independent predictors of postoperative bowel ischemia were established using multivariable logistic regression analysis. Results A total of 7312 patients were included, with 6668 intact (67.0% EVAR), and 644 ruptured AAA repairs (31.5% EVAR). The incidence of bowel ischemia following intact repair was 1.6% (open repair: 3.6%, EVAR: 0.6%), and 15.2% following ruptured repair (open repair: 19.3%, EVAR: 6.4%). Ruptured AAA was the most important determinant of postoperative bowel ischemia (OR:6.4, 95%CI:4.5 – 9.0), followed by open repair (OR:2.9, 95%CI:1.8 – 4.7). Additional predictive patient factors were advanced age (OR:1.4 per 10 years, 95%CI:1.1 – 1.7), female gender (OR:1.6, 95%CI:1.1 – 2.2), hypertension (OR:1.8, 95%CI:1.1 – 3.0), heart failure (OR:1.8, 95%CI:1.2 – 2.8), and current smoking (OR:1.5, 95%CI:1.1 – 2.1). Other risk factors included unilateral interruption of the hypogastric artery (OR:1.7, 95%CI:1.0 – 2.8), prolonged operative time (OR:1.2 per 60 min. increase, 95%CI:1.1 – 1.3), blood loss >1L (OR:2.0, 95%CI:1.3 – 3.0), and a distal anastomosis to the femoral artery (OR:1.7, 95%CI:1.1 – 2.7). Bowel ischemia patients had a significantly higher perioperative mortality after both intact (open repair: 20.5% vs. 1.9%, P<.001; EVAR: 34.6% vs. 0.9%, P<.001), as well ruptured AAA repair (open repair: 48.2% vs. 25.6%, P<.001; EVAR: 30.8% vs. 21.1%, P<.001). Conclusion This study underlines that although bowel ischemia following AAA repair is rare, the associated outcomes are very poor. The cause of postoperative bowel ischemia is multifactorial in nature, and can be attributed to patient factors, as well as operative characteristics. These data should be considered during pre-operative risk assessment, and optimization of both patient and procedure in an effort to reduce the risk of postoperative bowel ischemia.

Objectives It is unknown whether increased endovascular treatment of chronic mesenteric ischemia has led to decreases in open surgery, acute mesenteric ischemia, or overall mortality. The present study evaluates the trends in endovascular and open treatment over time for chronic and acute mesenteric ischemia. Methods We identified patients with chronic or acute mesenteric ischemia in the Nationwide Inpatient Sample and CDC database from 2000–2012. Trends in revascularization, mortality, and total deaths were evaluated over time. Data were adjusted to account for population growth. Results There were 14,810 revascularizations for chronic mesenteric ischemia (10,453 endovascular, 4,358 open), and 11,294 revascularizations for acute mesenteric ischemia (4,983 endovascular, 6,311 open). Endovascular treatment increased for both chronic (0.6 to 4.5/Million, P < 0.01) and acute mesenteric ischemia (0.6 to 1.8/Million, P < 0.01). However, concurrent declines in open surgery did not occur (chronic: 1 to 1.1/Million, acute: 1.8 to 1.7/Million). Among patients with acute mesenteric ischemia, the proportion with atrial fibrillation (18%) and frequency of embolectomy (1/Million per year) remained stable. In-hospital mortality rates decreased for both endovascular (chronic: 8% to 3%, P < 0.01; acute: 28% to 17%, P < 0.01) and open treatment (chronic: 21% to 9%, P < 0.01; acute: 40% to 25%, P < 0.01). Annual population-based mortality remained stable for chronic mesenteric ischemia (0.7 to 0.6 deaths per Million/year), but decreased for acute mesenteric ischemia (12.9 to 5.3 deaths per Million/year, P < 0.01). Conclusions Population mortality from acute mesenteric ischemia declined from 2000–2012, correlated with dramatic increases in endovascular intervention for chronic mesenteric ischemia, and in spite of a stable rate of embolization. However, open surgery for both chronic and acute ischemia remained stable.