conducted. The overall effects of year and procedure groups were significant (P ¼ .014; Fig 1). The hazard ratio of OSR pre-2007 was 1.54 (95% confidence interval, 0.75-3.16) indicating higher risk, and the hazard ratio of EVAR was 0.58 (95% confidence interval, 0.23-1.42) indicating a lower risk.Conclusions: Survival after RAAA has improved since 2007, primarily driven by an "EVAR-first" approach despite increased overall comorbidities. Survival in patients after open aneurysm repair has also improved; however, the difference did not reach statistical significance. EVAR is the best first-line therapy for rAAA at experienced centers.
Objectives: This preliminary study examined the technical efficacy and safety of treating acute limb occlusion after EVAR with pharmacomechanical thrombectomy (PMT) using the AngioJet rheolytic system.Methods: The technical aspects, success, and complications of the first seven consecutive patients presenting with acute limb occlusion after EVAR treated with PMT were analyzed. All patients underwent surgical femoral exposure to facilitate distal arterial control and limit distal embolization. Completion thrombectomy angiograms were reviewed to identify anatomical or structural causes for limb occlusion and subsequently treated accordingly. Technical success, distal embolization, major hemorrhagic complications, acute kidney injury, compartment syndrome, 30-day patency, and amputation-free survival were evaluated.Results: Six of seven patients (86%) presented with acute limb occlusion within 30 days of the original EVAR procedure. All patients were on antiplatelet therapy at time of presentation. Narrowing or kinking of the endograft limb was apparent on computed tomography scan in three patients (43%). An embolic etiology of limb occlusion was suspected in two patients (29%). The technical success rate with PMT treatment was 100%. All patients subsequently underwent EVAR limb stenting in the same procedure. There were no reported cases of distal embolization after PMT or major hemorrhagic complications. Two patients (29%) developed compartment syndrome after revascularization requiring lower leg fasciotomies. Furthermore, two patients (29%) developed acute kidney injury during their hospital admission. The 30-day patency and amputation-free survival rate for PMT was 100%. The overall mean length of stay in hospital for PMT treatment was 9.8 6 4.2 days.Conclusions: Early results of PMT with the AngioJet system represent a novel strategy for treating acute limb occlusion after EVAR that is safe and effective.
Objectives: Ruptured abdominal aortic aneurysm (RAAA) is associated with high morbidity and mortality. We evaluated our single-center experience with management of patients with RAAA. Methods: We reviewed our experience using a clinical research/quality improvement database with a historical cohort study design. Risk and diagnostic factors were assessed using only preoperative data. Longterm follow-up was completed by clinical contact and national death index. Data were analyzed by univariate and multivariable methods for discrete, continuous and survival data structures. Analyses were performed using SAS 9.4 software. Results: Between 2001 and 2016, we repaired 610 AAAs, of which 153 (25%) were RAAA. Patients with RAAAs were younger (median age, 70 vs 72 years; P < .003), mostly male (80% vs 20%; P ¼ .279), and 86.3% vs 21% (P < .001) were transferred from other facilities. RAAA patients commonly presented with diaphoresis (15.7% vs 1%; P < .001), hypotension (52% vs 1%; P < .001), pulsatile abdominal mass (12% vs 5%; P < .002), acute abdominal pain (82% vs 30%; P < .001), acute back pain (43% vs 16%; P < .001), or syncope or dizziness (23% vs 4%; P < .001) on admission. RAAA patients had more high-grade atheromatous disease (8% vs 2%; P < .001), mycotic aneurysm (5% vs 1%; P < .008), with greater median aneurysm size (8 vs 5.5 cm; P < .001). Women ruptured at a lower aortic size than men (7.4 vs 8.1 cm; P < .061). The 30-day death rate was 22% in rupture vs 4% in nonrupture (P < .001). In the RAAA subcohort, predictors of 30-day mortality were age >70 years (P < .04), glomerular filtration rate (GFR) <60 (P < .001), and hypotension (P < .042). No rupture patient died who did not have at least one of these risk factors (P < .001), and these were deemed high risk. Over a mean followup time of 7.7 years, long-term survival at 1 and 5 years was 66% and 54% among RAAA managed with open repair, compared to 84% and 72% among RAAA managed with endovascular repair, and 90% and 73% among nonruptured AAA (P < .001, Fig). In multivariable Cox regression, adjusted for age >70 years, rupture, chronic obstructive pulmonary disease and low GFR, EVAR was associated with a 1.5-fold reduction in hazard of long-term mortality (P > .0458). In adjusted multivariable analysis (adjusting for rupture and high-risk presentation), EVAR was associated with a 2.8-fold reduction in 30-day mortality (P < .008). Conclusions: Age >70, GFR <60 and hypotension were highly predictive of mortality in RAAA. EVAR was associated with reduced mortality and had favorable long-term outcomes even among high-risk population.
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