The majority of patients with acute type B dissection will fail medical therapy over time as evidenced by a 6-year intervention-free survival of 41%. Patients who underwent any aortic intervention had a significant survival advantage over those who were treated with medical management alone. Further study is necessary to determine who will benefit most from early intervention.

Although medical management of uncomplicated acute, type B aortic dissections has been the standard of care, at 5 years, a significant number of patients will require operative intervention for aneurysmal degeneration. Further studies of early intervention (eg, thoracic endovascular aortic repair) for type B aortic dissection to prevent late aneurysm formation are needed.

Introduction and objectives:Ultrasound-guided access allows for direct visualization of the access artery during percutaneous endovascular aneurysm repair (EVAR). We hypothesize that the use of ultrasound guidance allowed us to safely increase the use of percutaneous EVAR and to benefit from its lower rates of wound complications.Methods: A retrospective record review was performed of all elective EVAR from 2005 to 2010 at an academic tertiary care center. Patients were identified using International Classification of Diseases, 9th Revision, Clinical Modification codes and stratified by percutaneous vs femoral cutdown access. We examined the success rate of percutaneous access and the cause of failure. Sheath size was large (Ն16F) or small (Ͻ16F). Outcomes were wound complications (infections or clinically significant hematomas), operative time, length of stay, and discharge disposition. Predictors of percutaneous failure and femoral cutdown access were determined.Results: Percutaneous access was used in 141 patients (281 arteries) and femoral cutdown in 104 patients (208 arteries). Ultrasound-guided access was introduced in 2006. Percutaneous access increased from 0% in 2005 to 92.9% of elective EVAR in 2010. The remaining 7% had planned cutdown for concomitant femoral-femoral bypass. The success rate with percutaneous access was 95.1%. Failures included hemorrhage in eight and occlusion of the artery in five. Percutaneous access had fewer wound complications (0% vs 7.6%, P Յ .01) and shorter operative time (157.6 vs 207.5 minutes, P Յ .001). Length of stay (3.2 vs 4.1 days, P ϭ .09) and discharge home (91.5% vs 84.3%, P ϭ .08) had trends towards significance. No difference was seen in body mass index (26.6 vs 26.8 kg/m 2 , P ϭ .73). There were no predictors of femoral cutdown access. Only peripheral arterial disease predicted percutaneous failure (odds ratio, 4.59; 95% confidence interval, 1.27-15.57; P ϭ .025).Conclusions: Ultrasound guidance has prompted the increased use of percutaneous EVAR in nearly all elective EVAR cases. Percutaneous access has fewer wound complications and shorter operative time and can be performed safely with a high success rate.

The total number of DTA repairs has significantly increased. Operative mortality for TEVAR is independent of hospital volume and type, whereas mortality after open surgery is lower at HV hospitals, suggesting that TEVAR can be safely performed across a spectrum of hospitals, whereas open surgery should be performed only at HV hospitals.

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The presence of moderate or severe CKD in patients considered for AAA repair is associated with significantly increased mortality and therefore should figure prominently in clinical decision making. The high mortality of AAA repair in patients with severe CKD is such that elective repair in such patients is not advised, except in extenuating clinical circumstances.

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CKD severity is an important predictor of perioperative mortality and long-term survival after AAA repair in propensity-matched cohorts. The 5-fold increase in 30-day mortality and 44% in 3-year survival suggest that elective AAA repair is contraindicated in most severe CKD patients.