Objectives Endovascular abdominal aortic aneurysm repair (EVAR) is increasingly used for emergent treatment of ruptured abdominal aortic aneurysm (rAAA). We sought to compare the perioperative and long-term mortality, procedure-related complications and rates of re-intervention of EVAR versus open aortic repair of rAAA in Medicare beneficiaries. Methods We examined perioperative and long-term mortality and complications after EVAR or open aortic repair performed for rAAA in all traditional Medicare beneficiaries discharged from a US hospital from 2001–2008. Patients were propensity score matched on baseline demographics, coexisting conditions, admission source, and hospital volume of rAAA repair and sensitivity analyses were performed to evaluate the impact of bias that might have resulted from unmeasured confounders Results Of 10,998 patients with repaired rAAA, 1126 underwent EVAR and 9872 underwent open repair. Propensity score matching yielded 1099 patient pairs. The average age was 78 years, and 72.4% were male. Perioperative mortality for EVAR and open repair were 33.8% and 47.7% respectively (p<0.001) and this difference persisted for more than four years. EVAR patients had higher rates of AAA-related reinterventions when compared with open repair patients (endovascular reintervention at 36 months 10.9% vs 1.5%, p<0.001), whereas open patients had more laparotomy related complications (incisional hernia repair at 36 months 1.8% vs. 6.2% p<0.001, all surgical complications at 36 months 4.4% vs. 9.1%, p<0.001). Use of EVAR for rAAA has increased from 6% of cases in 2001 to 31% of cases in 2008, while over the same time period overall 30-day mortality for admission for rAAA regardless of treatment has decreased from 55.8% to 50.9%. Conclusions EVAR for rAAA is associated with lower perioperative and long term mortality in Medicare beneficiaries. Increasing adoption of EVAR for rAAA is associated with an overall decrease in mortality of patients hospitalized for rAAA over the last decade.

Objective To examine the modern epidemiology of abdominal aortic aneurysm (AAA) rupture and short-term AAA-related mortality after the introduction of endovascular aneurysm repair (EVAR). Background Prior epidemiologic studies have demonstrated stable rates of AAA repair, repair mortality, and AAA rupture. Recently, EVAR has been introduced as a less invasive treatment method and its use has expanded to over 75% of elective AAA repairs. Methods We identified Medicare beneficiaries undergoing AAA repair and those hospitalized with a ruptured AAA during the period 1995–2008 and calculated standardized annual rates of AAA-related deaths due to either elective repair or rupture. Results 338,278 patients underwent intact AAA repair over the study period. There were 69,653 patients with AAA rupture of whom 47,524 underwent repair. Intact repair rates increased substantially in those over age 80 (57.7 to 92.3 per 100,000, P<0.001), but decreased in those aged 65–74 (81.8 to 68.9, P<0.001). A decline in ruptures with and without repair was seen in all age groups. By 2008, 77% of all intact repairs and 31% of all rupture repairs were performed with EVAR (P<0.001). Operative mortality declined over the study period for both intact (4.9% to 2.4%, P<0.001) and ruptured (44.1% to 36.3%, P<0.001) AAA repair. Short-term AAA-related deaths decreased by more than half (26.1 to 12.1 per 100,000, P<0.001) with the greatest decline occurring in those over age 80 (53.7 to 27.3, P<0.001). Conclusions A recent decline in AAA rupture and short-term AAA-related mortality is demonstrated and likely related in part to the introduction and expansion of EVAR. This is due to decreased deaths from ruptures (with and without repair) and decreased mortality with intact repairs, particularly in patients over age 80.

Introduction Ultrasound guided access allows for direct visualization of the access artery during percutaneous endovascular aortic aneurysm repair. We hypothesize that the use of ultrasound guidance allowed us to safely increase the utilization of percutaneous endovascular aortic aneurysm repair to almost all patients and decrease access complications. Methods A retrospective chart review of all elective endovascular aortic aneurysm repairs, both abdominal and descending thoracic, from 2005-2010 was performed. Patients were identified using ICD9 codes and stratified based on access type: percutaneous vs. cutdown. We examined the success rate of percutaneous access and the cause of failure. Sheath size was large (18-24 Fr) or small (12-16 Fr). Minimum access vessel diameter was also measured. Outcomes were wound complications (infections or clinically significant hematomas that delayed discharge or required transfusion), operative and incision time, length of stay, and discharge disposition. Predictors of percutaneous failure were identified. Results 168 patients (296 arteries) had percutaneous access (P-EVAR) while 131 patients (226 arteries) had femoral cutdown access (C-EVAR). Ultrasound guided access was introduced in 2007. P-EVAR increased from zero cases in 2005 to 92.3% of all elective cases in 2010. The success rate with percutaneous access was 96%. Failures requiring open surgical repair of the artery included 7 for hemorrhage and 6 for flow limiting stenosis or occlusion of the femoral artery. P-EVAR had fewer wound complications (0.7% vs. 7.4%, P = .001) shorter operative time (153.3 vs. 201.5 minutes, P < .001) and larger minimal access vessel diameter (6.7 mm vs. 6.1 mm, P < .01). Patients with failed percutaneous access had smaller minimal access vessel diameters when compared to successful P-EVAR (4.9 mm vs. 6.8 mm, P < .001). More failures occurred in small sheaths than large ones (7.4% vs. 1.9%, P = .02). Access vessel diameter < 5 mm is predictive of percutaneous failure (16.7% of vessels < 5 mm failed vs. 2.4% of vessels ≥ 5 mm, P < .001) (OR 7.3, 95% CI [1.58-33.8], P = .01). Conclusion Ultrasound guided percutaneous EVAR can be performed in the vast majority of patients with a high success rate, shorter operative times, and fewer wound complications. Access vessel diameters less than 5 mm are at greater risk for percutaneous failure and should be treated selectively.

A bdominal aortic aneurysm (AAA) is an abnormal focal dilation of the aortic wall that affects 5% of men aged 60 years. The risk of aortic rupture increases with AAA size, and AAA rupture is associated with a 80% to 90% mortality rate.1 Currently, the only treatment option for AAA is open or endovascular surgery; however, there is significant interest in developing medical therapies to limit AAA growth and rupture. [2][3][4] Osteoprotegerin (OPG) is a secreted glycoprotein member of the tumor necrosis factor receptor superfamily.5 It acts as a decoy receptor for receptor activator of nuclear factor kB ligand (RANKL) and tumor necrosis factorrelated apoptosis-inducing ligand.6 Cells described to secrete OPG include osteoblasts, endothelial cells, human aortic vascular smooth muscle cells (VSMCs), dendritic cells, lymphocytes, and plasma cells. [7][8][9] OPG is a key regulator of bone remodeling 5,10 but has also been implicated in tumorigenesis, immunologic pathways, and vascular diseases. 6,7,[11][12][13][14][15] The precise role of OPG in vascular disease is currently controversial.Evidence from animal studies suggests that OPG prevents arterial calcification and stabilizes plaque formation. 16,17 However, clinical studies have associated serum OPG concentrations with the presence and progression of cardiovascular disease. [18][19][20][21] Circulating OPG concentrations have also been reported to be higher in patients with AAA and positively associated with AAA progression. 4,22 In vitro experiments have suggested that OPG stimulates matrix metalloprotease (MMP) secretion from human monocytes and VSMCs, and that OPG secretion is downregulated by irbesartan. 4 These data suggest a potential role of OPG in AAA; however, currently we are aware of no studies that have reported the concentration of OPG in human AAA biopsies.The aim of this study was to assess the concentration of OPG in a large number of AAA biopsies and assess whether OPG expression was related to markers of AAA severity. We hypothesized that OPG is locally produced in vessel walls of patients with AAA disease and is associated with markers of aortic proteolysis. Osteoprotegerin is Associated With Aneurysm diameter and Proteolysis in Abdominal Aortic Aneurysm disease Patient inclusionIn this study, consecutive patients undergoing open repair of intact or ruptured AAA were included. The indications for intervention were based on current guidelines and included the following: AAA diameter exceeding 55 mm for males, AAA diameters between 50 and 55 mm for females, rapidly expanding aortic diameters (5 mm in 6 months with a minimum diameter of 40 mm), saccular aneurysms, symptoms attributable to AAA and AAA rupture. 1,24 Patients with AAA diameters between 50 and 55 mm were selected for surgery based on the clinical judgment of the surgeon and in consultation with the patient. Open repair was performed in patients in whom AAAs were not anatomically suited for endovascular repair. Patients with terminal malignancies or severe dementia were excluded ...