Effect of ethnicity on access and device complications during endovascular aneurysm repair

Masuda, Elna M.; Michael, T; Singh, Niten; Yorita, Krista L.; Schneider, Peter A.; Sato, Dean T.; Eklöf, Bo; Nelken, Nicholas A; Kistner, Robert L.

doi:10.1016/j.jvs.2004.02.035

Cited by 48 publications

(42 citation statements)

References 9 publications

(12 reference statements)

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“…23, 24 However, even though aortic dissection seems to occur more frequently in Asian countries, most of the literature regarding the anatomy of aortic dissection 19,20,25-28 and the ascending aorta/aortic arch 29-33 comes from Caucasian countries, with only a few exceptions. 18,34, 35 In this study, we performed a retrospective analysis of 131 Japanese TAAD patients.…”

Section: Discussionmentioning

confidence: 99%

Anatomic Feasibility of Next-Generation Stent Grafts for the Management of Type A Aortic Dissection in Japanese Patients

Fujimura

Kawaguchi

Obara

et al. 2017

Circ J

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even in cases of uncomplicated TBAD, 12 and the application of this surgical technique to manage aortic dissection seems to be expanding.On the other hand, there have been only a few case series reported in the literature on the use of TEVAR for TAAD. 13-15 The use of this surgical technique for managing TAAD is complicated by multiple factors including the location of the coronary artery, involvement of arch vessels, and proximity of the aortic valve, among others, as all factors could, in theory, contribute to a potentially fatal outcome should operative complications arise. 16 The largest series reported is by Ye et al, 17 who reported the results of 45 TEVARs for Chinese patients with TAAD with excellent results. However, no large case series have been reported since, and it appears that TEVAR for TAAD is still not applicable using current devices.As a means of teasing out the anatomical problems of TAAD, a few feasibility studies have evaluated TEVAR for TAAD using the manufacturers' instructions for use S tanford type A aortic dissection (TAAD) remains the most lethal aortic emergency, with a 50% mortality rate within 48 h of onset. 1,2 The only available standard treatment is open surgical repair, 3,4 and although recent advances in perioperative management have led to improved outcomes, 5,6 TAAD is still associated with high rates of morbidity and mortality. 7-9 Moreover, because of high levels of surgical stress, approximately 20% of patients are still denied treatment. 1 Thoracic endovascular aneurysm repair (TEVAR) was originally developed as a treatment for aneurysms, but when used to close the primary entry tear (ET) of acute complicated type B aortic dissections (TBAD), it had favorable outcomes, including enlargement of the collapsed true lumen, increased flow through the true lumen, thrombus formation leading to occlusion in the false lumen, and ultimately, aortic remodeling to cure the dissection. It has already become the treatment of choice for complicated TBAD.

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Section: Discussionmentioning

confidence: 99%

Anatomic Feasibility of Next-Generation Stent Grafts for the Management of Type A Aortic Dissection in Japanese Patients

Fujimura

Kawaguchi

Obara

et al. 2017

Circ J

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“…22 Other studies have shown that the Asian population (men and women), who tend to be of smaller stature, are disadvantaged when being considered for endovascular aneurysm repair (EVAR), as the presence of smaller vessels is not conducive to easy deployment or long-term durability of the grafts. 23,24 Abdominal aortic aneurysms are four to six times more common in men than in women. 25 In addition, aneurysms develop in women approximately a decade later than in men.…”

Section: Epidemiology and Risk Factorsmentioning

confidence: 99%

The UK EndoVascular Aneurysm Repair (EVAR) randomised controlled trials: long-term follow-up and cost-effectiveness analysis

Patel

Powell

Sweeting

et al. 2018

Health Technol Assess

101

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BackgroundShort-term survival benefits of endovascular aneurysm repair (EVAR) compared with open repair (OR) of intact abdominal aortic aneurysms have been shown in randomised trials, but this early survival benefit is soon lost. Survival benefit of EVAR was unclear at follow-up to 10 years.ObjectiveTo assess the long-term efficacy of EVAR against OR in patients deemed fit and suitable for both procedures (EVAR trial 1; EVAR-1); and against no intervention in patients unfit for OR (EVAR trial 2; EVAR-2). To appraise the long-term significance of type II endoleak and define criteria for intervention.DesignTwo national, multicentre randomised controlled trials: EVAR-1 and EVAR-2.SettingPatients were recruited from 37 hospitals in the UK between 1 September 1999 and 31 August 2004.ParticipantsMen and women aged ≥ 60 years with an aneurysm of ≥ 5.5 cm (as identified by computed tomography scanning), anatomically suitable and fit for OR were randomly assigned 1 : 1 to either EVAR (n = 626) or OR (n = 626) in EVAR-1 using computer-generated sequences at the trial hub. Patients considered unfit were randomly assigned to EVAR (n = 197) or no intervention (n = 207) in EVAR-2. There was no blinding.InterventionsEVAR, OR or no intervention.Main outcome measuresThe primary end points were total and aneurysm-related mortality until mid-2015 for both trials. Secondary outcomes for EVAR-1 were reinterventions, costs and cost-effectiveness.ResultsIn EVAR-1, over a mean of 12.7 years (standard deviation 1.5 years; maximum 15.8 years), we recorded 9.3 deaths per 100 person-years in the EVAR group and 8.9 deaths per 100 person-years in the OR group [adjusted hazard ratio (HR) 1.11, 95% confidence interval (CI) 0.97 to 1.27;p = 0.14]. At 0–6 months after randomisation, patients in the EVAR group had a lower mortality (adjusted HR 0.61, 95% CI 0.37 to 1.02 for total mortality; HR 0.47, 95% CI 0.23 to 0.93 for aneurysm-related mortality;p = 0.031), but beyond 8 years of follow-up patients in the OR group had a significantly lower mortality (adjusted HR 1.25, 95% CI 1.00 to 1.56,p = 0.048 for total mortality; HR 5.82, 95% CI 1.64 to 20.65,p = 0.0064 for aneurysm-related mortality). The increased aneurysm-related mortality in the EVAR group after 8 years was mainly attributable to secondary aneurysm sac rupture, with increased cancer mortality also observed in the EVAR group. Overall, aneurysm reintervention rates were higher in the EVAR group than in the OR group, 4.1 and 1.7 per 100 person-years, respectively (p < 0.001), with reinterventions occurring throughout follow-up. The mean difference in costs over 14 years was £3798 (95% CI £2338 to £5258). Economic modelling based on the outcomes of the EVAR-1 trial showed that the cost per quality-adjusted life-year gained over the patient’s lifetime exceeds conventional thresholds used in the UK. In EVAR-2, patients died at the same rate in both groups, but there was suggestion of lower aneurysm mortality in those who actually underwent EVAR. Type II endoleak itself is not associated with a higher rate of mortality.LimitationsDevices used were implanted between 1999 and 2004. Newer devices might have better results. Later follow-up imaging declined, particularly for OR patients. Methodology to capture reinterventions changed mainly to record linkage through the Hospital Episode Statistics administrative data set from 2009.ConclusionsEVAR has an early survival benefit but an inferior late survival benefit compared with OR, which needs to be addressed by lifelong surveillance of EVAR and reintervention if necessary. EVAR does not prolong life in patients unfit for OR. Type II endoleak alone is relatively benign.Future workTo find easier ways to monitor sac expansion to trigger timely reintervention.Trial registrationCurrent Controlled Trials ISRCTN55703451.FundingThis project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and the results will be published in full inHealth Technology Assessment; Vol. 22, No. 5. See the NIHR Journals Library website for further project information.

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“…41,42 Similar anatomic problems have been seen with aortoiliac stent grafting for Hawaiian patients of Asian ancestry. 43 In brief, one should keep in mind that performance of thrombectomy without careful consideration of the cause of arterial occlusion may be harmful to patients with atherothrombotic occlusion.…”

Section: Essential Issues For Acute Evt In Asiamentioning

confidence: 99%

Acute Reperfusion Therapy and Stroke Care in Asia After Successful Endovascular Trials

Toyoda

Koga

Hayakawa

et al. 2015

Stroke

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Abstract-The current status of and prospects for acute stroke care in Asia in the situation where both intravenous thrombolysis and endovascular therapies have been recognized as established strategies for acute stroke are reviewed. Of 15 million people annually having stroke worldwide, ≈9 million are Asians. The burdens of both ischemic and hemorrhagic strokes are severe in Asia. The unique features of stroke in Asia include susceptibility to intracranial atherosclerosis, high prevalence of intracerebral hemorrhage, effects of dietary and lifestyle habits, and several disorders with genetic causes. These features affect acute stroke care, such as the dosage of alteplase for thrombolysis and consideration of bleeding complications during antithrombotic therapy. Acute endovascular thrombectomy, as well as intravenous thrombolysis, is relatively prevalent in East Asia, but most of the other Asian countries need to develop their human resources and fundamental medical infrastructure for stroke care. A limitation of endovascular therapy in East Asia is the high prevalence of intracranial atherosclerosis that can cause recanalization failure and require additional angioplasty or permanent stent insertion although intracranial stenting is not an established strategy. Multinational collaboration on stroke research among Asian countries is infrequent. Asians should collaborate to perform their own thrombolytic and endovascular trials and seek the optimal strategy for stroke care specific

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Effect of ethnicity on access and device complications during endovascular aneurysm repair

Cited by 48 publications

References 9 publications

Anatomic Feasibility of Next-Generation Stent Grafts for the Management of Type A Aortic Dissection in Japanese Patients

Anatomic Feasibility of Next-Generation Stent Grafts for the Management of Type A Aortic Dissection in Japanese Patients

The UK EndoVascular Aneurysm Repair (EVAR) randomised controlled trials: long-term follow-up and cost-effectiveness analysis

Acute Reperfusion Therapy and Stroke Care in Asia After Successful Endovascular Trials

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