Asunto(s)

Aorta Torácica , Rotura de la Aorta , Humanos , Rotura de la Aorta/diagnóstico por imagen , Rotura de la Aorta/etiología , Rotura de la Aorta/cirugía , Aorta Torácica/diagnóstico por imagen , Aorta Torácica/cirugía , Aorta Torácica/lesiones , Masculino , Angiografía por Tomografía Computarizada , Persona de Mediana Edad , Resultado del Tratamiento

RESUMEN

OBJECTIVE: The prevalence of abdominal aortic aneurysms (AAA) increases with age. Elective intervention for AAA is critical to prevent rupture associated with very high mortality among older males. METHODS: The aim of this study was to address the impact of post-contrast acute kidney-PC-AKI injury among patients treated with endovascular repair of ruptured AAA-EVAR on outcomes such as new onset chronic kidney disease-CKD and mortality among patients within a two-year trial. RESULTS: The same study group (of n = 192 patients) underwent reassessment, two years after EVAR treatment. The overall mortality rate was 16.67%, and it was higher in the AKI group - 38.89%. CKD patients had a mortality rate of 23.88% (n = 16). Among patients with an aneurysm diameter >67 mm mortality rate reached 20% (n = 6), while in the previously reported diabetes mellitus group 37.93% (n = 11). New onset of CKD was diagnosed in 23% of cases. Preexisting CKD patients with PC- AKI contributed to a 33.33% mortality rate (n = 8). CONCLUSION: This study concludes that PC-AKI impacts outcomes and survival in endovascularly treated AAAs. Type 2 diabetes and preexisting chronic kidney disease are associated with higher mortality within a 2-year follow-up, however gender factor was not significant. A larger aneurysm diameter is related with a higher prevalence of PC-AKI. These factors should be taken into account during screening, qualifying patients for the treatment and treating patients with AAA. It may help to identify high-risk individuals and tailor preventive measurements and treatment options accordingly, improving treatment results and reducing mortality.

Asunto(s)

Lesión Renal Aguda , Aneurisma de la Aorta Abdominal , Rotura de la Aorta , Procedimientos Endovasculares , Insuficiencia Renal Crónica , Humanos , Aneurisma de la Aorta Abdominal/cirugía , Aneurisma de la Aorta Abdominal/mortalidad , Aneurisma de la Aorta Abdominal/complicaciones , Masculino , Procedimientos Endovasculares/efectos adversos , Femenino , Anciano , Factores de Riesgo , Rotura de la Aorta/cirugía , Rotura de la Aorta/mortalidad , Insuficiencia Renal Crónica/complicaciones , Insuficiencia Renal Crónica/mortalidad , Insuficiencia Renal Crónica/epidemiología , Lesión Renal Aguda/etiología , Lesión Renal Aguda/mortalidad , Anciano de 80 o más Años , Persona de Mediana Edad , Medios de Contraste

RESUMEN

INTRODUCTION: Sinus of Valsalva aneurysm (SOVA), a rare cardiac malformation, is usually congenital and rarely acquired and most commonly occurring in the right coronary sinus. The clinical presentation of patients with SOVA varies. It is usually asymptomatic when it has not ruptured, and when it compresses neighboring structures or ruptures, it can lead to heart failure or shock, at which point urgent surgical intervention is usually required. Rupture of the sinus of Valsalva aneurysm (RSOVA) during pregnancy is really hard to come by, especially if the clinical presentations resemble that of an acute myocardial infarction. This report describes a pregnant woman with severe chest pain and hypotension with aVR and V1 ST-segment elevation due to RSOVA. PATIENT CONCERNS: Effects of RSOVA on the fetus, disease survival, and prognosis. DIAGNOSIS: RSOVA. INTERVENTIONS: Open SOVA repair. OUTCOMES: The patient's blood pressure returned to normal range and clinical symptoms disappeared after the surgery. After 3 months of follow-up, the patient was hemodynamically stable without chest discomfort, and an echocardiogram showed a normal aortic sinus. CONCLUSION: Progressive aneurysm dilatation or rupture has a poor prognosis. A thorough history and physical examination are fundamental, with echocardiography being the initial diagnostic tool of choice, and other ancillary tests (e.g., computed tomography) being used to complement and confirm the diagnosis. Surgery remains the current treatment of choice for patients with RSOVA, while the continuation of pregnancy in pregnant patients with RSOVA remains a case-by-case measure.

Asunto(s)

Complicaciones Cardiovasculares del Embarazo , Choque Cardiogénico , Seno Aórtico , Humanos , Embarazo , Femenino , Complicaciones Cardiovasculares del Embarazo/diagnóstico , Adulto , Choque Cardiogénico/etiología , Choque Cardiogénico/diagnóstico , Seno Aórtico/diagnóstico por imagen , Seno Coronario/anomalías , Rotura de la Aorta/diagnóstico , Rotura de la Aorta/complicaciones , Rotura de la Aorta/cirugía , Aneurisma de la Aorta/complicaciones , Aneurisma de la Aorta/diagnóstico , Aneurisma de la Aorta/cirugía , Electrocardiografía , Ecocardiografía

RESUMEN

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is indicated for elderly patients who often have severe comorbidities and high operative risk. Despite many advantages, it carries the potential for both early and late complications. The literature reports mainly periprocedural problems. This case report describes a rare instance of ascending aortic rupture as a late complication following TAVI. CASE PRESENTATION: An 81-year-old male with severe aortic stenosis (AS) was a non-surgical patient due to a high operative risk (EuroSCORE II 14.08%) and comorbidities, including cardiovascular problems, chronic obstructive pulmonary disease, myelodysplastic syndrome. During the TAVI procedure Medtronic CoreValve™ Evolut™ R-26 was implanted via the right femoral artery. Postoperative period elapsed without complications and the patient was discharged home. Six months later, the patient was re-admitted to the hospital on an emergency basis and transferred directly to the operating room due to ascending aortic rupture (EuroSCORE II 53.20%, GERAADA score 64.9%). Computed tomography angiography (CTA) showed aortic rupture with a multiple fresh blood reservoirs and thrombus around the ascending aorta originating from the spot where the nitinol frame of the TAVI valve was attached to the native aorta. Supracoronary excision of the ascending aorta with implantation of a vascular graft (Intergard Woven Graft 34 mm) was performed, preserving the earlier implanted TAVI valve. On the 9th day after surgery the patient's general condition deteriorated, he suffered from circulatory and respiratory insufficiency. Furthermore, a gastrointestinal bleeding with the need for gastro-, and colonoscopy and multiple blood transfusions occurred. Patient developed urosepsis and acute renal failure with the need for hemodiafiltration. Despite intensive treatment, further deterioration of the medical condition of the patient. and finally the multiple organ failure was observed. Patient died on the 50th postoperative day. CONCLUSIONS: TAVI is a safe method of treating severe AS, especially recommended for non-surgical candidates. Rupture of the ascending aorta is a rare but serious complication of TAVI that usually occur during or shortly after the procedure. This case report highlights the importance of post-procedural monitoring for such TAVI complications, even in the late period following TAVI, and if such complications occur, taking the risk to perform a life-saving operation.

Asunto(s)

Rotura de la Aorta , Estenosis de la Válvula Aórtica , Reemplazo de la Válvula Aórtica Transcatéter , Anciano de 80 o más Años , Humanos , Masculino , Aorta/diagnóstico por imagen , Aorta/cirugía , Rotura de la Aorta/diagnóstico por imagen , Rotura de la Aorta/etiología , Rotura de la Aorta/cirugía , Estenosis de la Válvula Aórtica/cirugía , Angiografía por Tomografía Computarizada , Prótesis Valvulares Cardíacas/efectos adversos , Complicaciones Posoperatorias/diagnóstico por imagen , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/cirugía , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversos , Reemplazo de la Válvula Aórtica Transcatéter/instrumentación

RESUMEN

Persistent sciatic artery( PSA) is a rare congenital anomaly and often results in aneurismal or occlusive changes. A 82-year-old woman was reffered with diagnosis of Stanford type A acute aortic dissection complicated cardiac tamponade. Emergent aortic arch replacement was performed. Cardiopulmonary bypass was established by central cannulation into true lumen of aortic arch because of asceding aortic rupture during the operation, axillary arteries dissection and hypoplastic femoral arteries. Post-operative course was uneventful. She was transferred to the local hospital 32 days after the operation for the purpose of rehabilitation.

Asunto(s)

Disección Aórtica , Humanos , Femenino , Anciano de 80 o más Años , Disección Aórtica/cirugía , Disección Aórtica/complicaciones , Disección Aórtica/diagnóstico por imagen , Enfermedad Aguda , Rotura de la Aorta/cirugía , Rotura de la Aorta/diagnóstico por imagen , Rotura de la Aorta/complicaciones , Aneurisma de la Aorta Torácica/cirugía , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/complicaciones , Resultado del Tratamiento

RESUMEN

ABSTRACT: Advanced pregnancy is associated with a higher risk of complicated aortopathies owing to the physiologic changes in pregnancy. The diagnosis can be elusive due to its rare incidence. The optimal treatment strategy is chosen based on the clinical condition of the patient, gestational age, and the severity of the aortic disease. A healthy young primigravida presented with acute chest pain in the early second trimester, diagnosed as a thoracic aortic aneurysm that had ruptured causing hemothorax. She underwent emergency endovascular repair under general anesthesia. Aortic disease should always be ruled out early in acute chest pain in pregnancy. Expeditious and strategic management helps improve maternal and fetal outcomes.

Asunto(s)

Rotura de la Aorta , Procedimientos Endovasculares , Complicaciones Cardiovasculares del Embarazo , Humanos , Femenino , Embarazo , Procedimientos Endovasculares/métodos , Complicaciones Cardiovasculares del Embarazo/cirugía , Complicaciones Cardiovasculares del Embarazo/terapia , Adulto , Rotura de la Aorta/cirugía , Rotura de la Aorta/diagnóstico por imagen , Aneurisma de la Aorta Torácica/cirugía , Anestesia General/métodos

RESUMEN

Pseudoaneurysms are false aneurysms that mostly occur at the site of arterial injury. Pseudoaneurysm is the most frequent complication after catheter-associated interventions and occurs because of an insufficient closure of the puncture site. However, there are several reported cases of patients with pseudoaneurysm without a prior history of vascular intervention. We described a case of ruptured giant abdominal aortic pseudoaneurysm in a patient with no prior history of vascular intervention, with an initial complaint of abdominal pain. The patient successfully received EVAR therapy using a kissing graft.

Asunto(s)

Aneurisma Falso , Aneurisma de la Aorta Abdominal , Humanos , Aneurisma Falso/etiología , Aneurisma Falso/diagnóstico por imagen , Aneurisma de la Aorta Abdominal/cirugía , Aneurisma de la Aorta Abdominal/complicaciones , Masculino , Rotura de la Aorta/cirugía , Rotura de la Aorta/etiología , Rotura de la Aorta/diagnóstico por imagen , Dolor Abdominal/etiología , Rotura Espontánea , Procedimientos Endovasculares , Aorta Abdominal/diagnóstico por imagen , Tomografía Computarizada por Rayos X , Implantación de Prótesis Vascular , Persona de Mediana Edad

RESUMEN

OBJECTIVE: The objective of this study was to report long-term results of an ongoing physician-sponsored, investigational device exemption (IDE) pivotal clinical trial using physician-modified endovascular grafts (PMEGs) for the treatment of patients with juxtarenal aortic aneurysms. METHODS: Data from a nonrandomized, prospective, consecutively enrolling IDE clinical trial were used. Data collection began on April 1, 2011, and data lock occurred on January 2, 2024, with outcomes analysis through December 31, 2023. Primary safety and effectiveness end points were used to measure treatment success. The safety end point was defined as the proportion of subjects who experienced a major adverse event within 30 days of the procedure. The effectiveness end point was the proportion of subjects who achieved treatment success. Treatment success required the following at 12 months: technical success, defined as successful delivery and deployment of a PMEG with preservation of intended branch vessels; and freedom from: type I and III endoleak, stent graft migration >10 mm, aortic aneurysm sack enlargement >5 mm, and aortic aneurysm rupture or open conversion. RESULTS: Over the 12-year study period, 228 patients were enrolled; 205 began the implant procedure, and 203 received PMEG. Thirteen patients withdrew prior to PMEG. Two withdrew (<1.0%) after failure to deploy due to tortuous iliac anatomy and are tracked as intent to treat, and a total of 24 withdrew after receiving the PMEG implant. Forty-four patients died during the study period. A total of 14 were deemed lost to follow-up. Fifty-nine completed the 5-year follow-up period, and 62 remain active in follow-up visits.Aneurysm anatomy, operative details, and lengths of stay were recorded and included: aneurysm diameter (mean, 67.5 mm; range, 49-124 mm), proximal seal zone length (mean, 41.6 mm; range, 18.9-92.9 mm), graft modification time (mean, 48.7 min), procedure time (mean, 137.7 min), fluoroscopy time (mean, 33.8 min), contrast material use (mean, 93.0 mL), estimated blood loss (mean, 118.8 mL), length of hospital stay (mean, 3.7 d), and intensive care unit length of stay (mean, 1.6 d).A total of 575 fenestrations were created for 387 renal arteries, 181 superior mesenteric arteries (SMAs), and 7 celiac arteries. Renal arteries were in 96% of patients and included 410 renal artery stents in 203 patients. The SMA was stented as needed and included one patient with an SMA stent placed before the procedure, 19 during the procedure, and 2 patients who underwent stent placement after the procedure. There were no open conversions or device migrations and 1 partial explant due to late distal graft occlusion. Three ruptures (1.4%) were recorded on days 830, 1346, and 1460. There was 1 presumed graft infection at 750 days (<0.5%) treated with? Thirty-day all-cause mortality was 2.9% (6/204). One type Ia, 1 type Ib, and 7 type III endoleaks were identified during follow-up and treated with successful reintervention at the 1-year period. The overall rate of major adverse events at 30 days was 15% (29/194). Technical success was 93.7%, and overall treatment success was 82.6%. CONCLUSIONS: PMEG can be performed with low rates of long-term morbidity and mortality, confirming our early and midterm reports that endovascular repair with PMEG is safe, durable, and effective for managing patients with juxtarenal aortic aneurysms. While historically considered experimental, these results suggest that PMEG is a safe and durable option and should be considered for patients where off-the-shelf devices are not available.

Asunto(s)

Aneurisma de la Aorta Abdominal , Rotura de la Aorta , Prótesis Vascular , Procedimientos Quirúrgicos Electivos , Procedimientos Endovasculares , Diseño de Prótesis , Humanos , Aneurisma de la Aorta Abdominal/cirugía , Masculino , Femenino , Anciano , Procedimientos Endovasculares/métodos , Estudios Prospectivos , Rotura de la Aorta/cirugía , Procedimientos Quirúrgicos Electivos/métodos , Resultado del Tratamiento , Implantación de Prótesis Vascular/métodos , Persona de Mediana Edad , Stents , Anciano de 80 o más Años , Complicaciones Posoperatorias/epidemiología , Estudios de Seguimiento , Factores de Tiempo

RESUMEN

OBJECTIVE: Type B intramural hematoma (IMH) is often managed medically, yet may progress to dissection, aneurysmal dilation, or rupture. The aim of this study was to report the natural history of medically managed Type B IMH, and factors associated with progression. METHODS: We reviewed patients with medically managed Type B IMH between January 1995 to December 2022 at a single center. Any patients with immediate surgical or endovascular intervention were excluded. Demographic profiles, comorbidities, imaging, and follow-up details were reviewed. Patients were divided into two groups: Group 1 had isolated IMH, and Group 2 had IMH along with aneurysm or dissection at the time of presentation. On follow-up, progression was defined as degeneration to aneurysm/dissection or increase in the thickness of IMH in Group 1. In Group 2, progression was an increase in the size of aneurysm or development of new dissection. RESULTS: Of 104 patients with Type B IMH during the study period, 92 were medically managed. The median age was 77 years, and 45 (48.9%) were females. Comorbidities included hypertension (83.7%), hypercholesterolemia (44.6%), and active smoking (47.8%). Mean Society for Vascular Surger comorbidity score was 6.3. Mean IMH thickness and aortic diameter at presentation were 8.9 mm and 38.3 mm, respectively. Median follow-up was 55 months. Overall survival at 1 year and 5 years was 85.8% and 61.9%, respectively. During follow-up, 19 patients (20.7%) required intervention, more common in Group 2 (Group 1, 8/66; 12.3% vs Group 2, 11/26; 42.3%; P = .001). This resulted in higher freedom from intervention in Group 1 at 1 year (93.5% vs 62.7%) and 5 years (87.5% vs 51.1%; P < .001). Indication for intervention was dissection (n = 4), aneurysm (n = 12), and progression of IMH (n = 3). In Group 1, progression was seen in 25 (37.9%), three (4.5%) remained stable, 29 (43.9%) had complete resolution of IMH, and nine patients were lost to follow-up. In Group 2, 11 patients (42.3%) had progression, seven (26.9%) remained stable, and eight were lost to follow-up. IMH thickness at presentation >7.2 mm is associated with both increased odds of progression (odds ratio, 3.3; 95% confidence interval, 1.2-11.1; P = .03) and intervention (odds ratio, 5.5; 95% confidence interval, 1.3-36.9; P = .03) during the follow-up. CONCLUSIONS: Although many patients with Type B IMH managed medically stabilize or regress, progression or need for intervention can occur in up to 40% of cases. This is associated with the presence of aneurysm, dissection, and IMH thickness. Long-term follow-up is mandatory as late interventions occur, particularly for higher risk patients.

Asunto(s)

Disección Aórtica , Progresión de la Enfermedad , Hematoma , Humanos , Femenino , Masculino , Hematoma/diagnóstico por imagen , Hematoma/terapia , Hematoma/mortalidad , Anciano , Estudios Retrospectivos , Factores de Tiempo , Factores de Riesgo , Disección Aórtica/diagnóstico por imagen , Disección Aórtica/terapia , Disección Aórtica/mortalidad , Anciano de 80 o más Años , Persona de Mediana Edad , Resultado del Tratamiento , Medición de Riesgo , Rotura de la Aorta/diagnóstico por imagen , Rotura de la Aorta/mortalidad , Rotura de la Aorta/cirugía , Rotura de la Aorta/terapia

RESUMEN

BACKGROUND: In the endovascular aneurysm repair era, open surgical repair (OSR) is performed for ruptured abdominal aorta aneurysm (RAAA) in patients with complex aneurysm neck and technical difficulties. Understanding the risk factors of OSR is essential for the clinical selection of the ideal surgical procedure. We aimed to re-evaluate the outcomes of OSR and treatment options for RAAA. METHODS: Patients who underwent OSR for RAAA between January 2010 and December 2022 were enrolled in this single-center retrospective observational study. Preoperative status, operative findings, and postoperative course were retrospectively reviewed. The Cox proportional hazards model was used to evaluate the association between age and early postoperative mortality. RESULTS: Among 142 patients, 43 (30.3%) and 99 (69.7%) were aged ≥80 and <80 years, respectively. Postoperative mortality within 30 days occurred in 24 (16.9%) patients (11/43 [25.6%] and 13/99 [13.1%] patients aged ≥80 and <80 years, respectively; hazard ratio = 1.95; P = 0.069). In a multivariable analysis, increased postoperative mortality within 30 days was associated with age ≥80 years (adjusted hazard ratio, aHR = 2.36; P = 0.049), the presence of preoperative or intraoperative cardiopulmonary arrest (aHR = 12.0; P < 0.001), and postoperative gastrointestinal disorder (aHR = 4.42; P = 0.003). CONCLUSIONS: Endovascular aneurysm repair may be preferable in older people; however, its use in cases of preoperative or intraoperative cardiopulmonary arrest or perioperative gastrointestinal disorders remains controversial, and a careful discussion on the surgical indications is needed in such cases.

Asunto(s)

Aneurisma de la Aorta Abdominal , Rotura de la Aorta , Implantación de Prótesis Vascular , Humanos , Estudios Retrospectivos , Aneurisma de la Aorta Abdominal/cirugía , Aneurisma de la Aorta Abdominal/mortalidad , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Masculino , Femenino , Anciano de 80 o más Años , Factores de Riesgo , Resultado del Tratamiento , Rotura de la Aorta/cirugía , Rotura de la Aorta/mortalidad , Rotura de la Aorta/diagnóstico por imagen , Factores de Edad , Factores de Tiempo , Medición de Riesgo , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/mortalidad , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/mortalidad , Anciano , Urgencias Médicas

RESUMEN

BACKGROUND: An aortoesophageal fistula can prove to be fatal. Salvage thoracic endovascular aortic repair as a bridging therapy and radical surgery with thoracotomy should be considered while treating aortoesophageal fistula without spontaneous closure. Moreover, it is essential to select a technique that reduces the risk of reinfection. Here we report a rare case of a ruptured thoracic aortic aneurysm related to esophageal perforation by a fish bone that led to massive hematemesis and shock, and the surgical treatment of an aortoesophageal fistula that developed after salvage thoracic endovascular aortic repair. CASE PRESENTATION: A 70-year-old Japanese female patient was admitted with hematemesis, thoracic pain, and shock related to esophageal perforation of a ruptured descending aortic aneurysm caused by fish bone aspiration and esophageal perforation 1 month previously. An emergency thoracic endovascular aortic repair was performed. Postoperatively, an aortoesophageal fistula that remained open and a food intake-related increase in the inflammatory response was noted. Radical blood-vessel prosthesis implantation and fistula closure were performed. The patient's postoperative course was favorable and the patient was discharged 22 days after the blood vessel prosthesis implantation. CONCLUSION: Such a case of rupture of a descending aortic aneurysm related to perforation by a fish bone and an aortoesophageal fistula is considerably rare. Thus, we report the therapeutic strategy of this particular case and review the relevant literature.

Asunto(s)

Aneurisma de la Aorta Torácica , Rotura de la Aorta , Procedimientos Endovasculares , Fístula Esofágica , Perforación del Esófago , Humanos , Femenino , Fístula Esofágica/cirugía , Fístula Esofágica/etiología , Anciano , Procedimientos Endovasculares/métodos , Aneurisma de la Aorta Torácica/cirugía , Rotura de la Aorta/cirugía , Perforación del Esófago/cirugía , Perforación del Esófago/etiología , Fístula Vascular/cirugía , Fístula Vascular/etiología , Implantación de Prótesis Vascular , Terapia Recuperativa/métodos , Animales , Hematemesis/etiología , Enfermedades de la Aorta/cirugía , Enfermedades de la Aorta/etiología , Aorta Torácica/cirugía , Resultado del Tratamiento , Peces , Reparación Endovascular de Aneurismas

RESUMEN

BACKGROUND: Variation in the care management of repairs for ruptured infrarenal abdominal aortic aneurysms between centers and physicians, such as procedural volumes, may explain differences in mortality outcomes. First, we quantified the center and physician variability associated with 30- and 90-day mortality risk after ruptured open surgical repair (rOSR) and ruptured endovascular aneurysm repair (rEVAR). Second, we explored wheter part of this variability was attributable to procedural volume at the center and physician levels. METHODS: Two cohorts including rOSR and rEVAR procedures between 2013 and 2019 were analyzed from the Vascular Quality Initiative database. Thirty- and 90-day all-cause mortality rates were derived from linked Medicare claims data. The median odds ratio (MOR) (median mortality risk from low- to high-risk cluster) and intraclass correlation coefficient (ICC) (variability attributable to each cluster) for 30- and 90-day mortality risks associated with center and physician variability were derived using patient-level adjusted multilevel logistic regression models. Procedural volume was calculated at the center and physician levels and stratified by quartiles. The models were sequentially adjusted for volumes, and the difference in ICCs (without vs with accounting for volume) was calculated to describe the center and physician variability in mortality risk attributable to volumes. RESULTS: We included 450 rOSRs (mean age, 74.5 ± 7.6 years; 23.5% female) and 752 rEVARs (76.4 ± 8.4 years; 26.1% female). After rOSRs, the 30- and 90-day mortality rates were 32.9% and 38.7%, respectively. No variability across centers and physicians was noted (30- and 90-day MORs ≈1 and ICCs ≈0%). Neither center nor physician volume was associated with 30-day (P = .477 and P = .796) or 90-day mortality (P = .098 and P = .559). After rEVAR, the 30- and 90-day mortality rates were 21.3% and 25.5%, respectively. Significant center variability (30-day MOR, 1.82 [95% confidence interval (CI), 1.33-2.22]; ICC, 11% [95% CI, 2%-36%]; and 90-day MOR, 1.76 [95% CI, 1.37-2.09]; ICC, 10% [95% CI, 3%-30%]), but negligeable variability across physicians (30- and 90-day MORs ≈1 and ICCs ≈0%) were noted. Neither center nor physician volume were associated with 30-day (P = .076 and P = .336) or 90-day mortality risk (P = .066 and P = .584). The center variability attributable to procedural volumes was negligeable (difference in ICCs, 1% for 30-day mortality; 0% for 90-day mortality). CONCLUSIONS: Variability in practice from center to center was associated with short-term mortality outcomes in rEVAR, but not for rOSR. Physician variability was not associated with short-term mortality for rOSR or rEVAR. Annualized center and physician volumes did not significantly explain these associations. Further work is needed to identify center-level factors affecting the quality of care and outcomes for ruptured abdominal aortic aneurysms.

Asunto(s)

Aneurisma de la Aorta Abdominal , Rotura de la Aorta , Procedimientos Endovasculares , Humanos , Aneurisma de la Aorta Abdominal/cirugía , Aneurisma de la Aorta Abdominal/mortalidad , Masculino , Femenino , Rotura de la Aorta/cirugía , Rotura de la Aorta/mortalidad , Anciano , Estados Unidos , Factores de Tiempo , Procedimientos Endovasculares/mortalidad , Procedimientos Endovasculares/efectos adversos , Factores de Riesgo , Medición de Riesgo , Anciano de 80 o más Años , Resultado del Tratamiento , Estudios Retrospectivos , Bases de Datos Factuales , Pautas de la Práctica en Medicina , Implantación de Prótesis Vascular/mortalidad , Implantación de Prótesis Vascular/efectos adversos , Disparidades en Atención de Salud , Medicare , Hospitales de Alto Volumen , Cirujanos

RESUMEN

BACKGROUND: We evaluate the relationship between the hospital case volume (HCV) and mortality outcomes after open aortic repair (OAR) and endovascular aortic repair (EVAR) of intact (iEVAR) and ruptured (rEVAR) abdominal aortic aneurysm (AAA) using a contemporary administrative database. METHODS: The Healthcare Cost and Utilization Project Database for New York (2016) and New Jersey/Maryland/Florida (2016-2017) were queried using International Classification of Disease-10th edition to identify patients who had undergone OAR and EVAR. The hospitals were categorized into quartiles (Q) per overall (EVAR + OAR) volume, OAR-alone volume and EVAR-alone volume. Cox regression adjusted for confounding factors was used to estimate hazard ratios (HRs) for mortality. RESULTS: A total of 8,825 patients (mean age, 73.5 ± 9.5 years; 6,861 male [77.7%]) had undergone 1,355 OARs and 7,470 EVARs. Overall HCV had no impact on in-hospital mortality across quartiles after (iEVAR) (range, 0.7%-1.4%, P = 0.15), (rEVAR) (range, 20.5%-29.6%, P = 0.63) and open repair of intact AAA (iOAR) (range, 4.9%-8.8%, P = 0.63). However, the mortality rates after open repair of ruptured AAA (rOAR) in highest-volume (Q4) hospitals were significantly lower than those in the 3 lower quartile hospitals (23.1% vs. 44.7%, P < 0.001). When analyzed per OAR-alone volume, the same findings were observed (22.0% for Q4 vs. 41.6% for Q1-3, P < 0.001). Furthermore, in Q4 hospitals per the OAR-alone volume analysis, the mortality hazard was greater for rEVAR (39.0%) than for rOAR (22.0%) (HR = 2.3, 95% confidence interval, 1.02-5.34, P < 0.05). CONCLUSIONS: The mortality rates for iEVAR, rEVAR and iOAR were independent of HCV. However, after rOAR, mortality rates in high OAR volume hospitals were lower than those in the lower quartile hospitals, and, at least comparable to those of rEVAR. EVAR-first strategy for ruptured AAA might not be applicable to all cases. Patent-specific, individualized treatment should be the gold standard. For patients requiring rOAR, transfer to a regional center of excellence, when clinical safe, should be encouraged.

Asunto(s)

Aneurisma de la Aorta Abdominal , Rotura de la Aorta , Reparación Endovascular de Aneurismas , Mortalidad Hospitalaria , Hospitales de Alto Volumen , Hospitales de Bajo Volumen , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Aneurisma de la Aorta Abdominal/cirugía , Aneurisma de la Aorta Abdominal/mortalidad , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Rotura de la Aorta/cirugía , Rotura de la Aorta/mortalidad , Rotura de la Aorta/diagnóstico por imagen , Bases de Datos Factuales , Reparación Endovascular de Aneurismas/efectos adversos , Reparación Endovascular de Aneurismas/mortalidad , Complicaciones Posoperatorias/mortalidad , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Estados Unidos

RESUMEN

Objective: To examine the perioperative clinical features and prognosis of patients with ruptured abdominal aortic aneurysms (rAAA) who received surgical repair. Methods: The clinical data of rAAA patients who underwent surgical repair and were admitted to the Surgical Intensive Care Unit of Beijing Anzhen Hospital, Capital Medical University from August 2005 to November 2020 were retrospectively analyzed, including the general clinical features, surgical mode, intraoperative conditions, postoperative complications, and fatality rate. Results: There were 117 patients with rAAA, with a median age of 68 (62,77) years, including 93 men (79.5%) and 24 women (20.5%). The main clinical manifestation was abdominal pain (n=115, 98.3%). Among them, 65 (55.6%) patients underwent endovascular aneurysm repair (EVAR), while 52 (44.4%) underwent open surgical repair (OSR). The common postoperative complications include acute gastrointestinal dysfunction (n=116, 99.1%), shock (n=89, 76.1%), acute respiratory distress syndrome (n=85, 72.6%), pancreatic injury (n=56, 47.9%), coagulation dysfunction (n=55, 47.0%), disseminated intravascular coagulation (n=46, 39.3%), acute kidney injury (n=39, 33.3%), infection/sepsis (n=28, 23.9%), gastrointestinal bleeding (n=17, 14.5%), and abdominal compartment syndrome (n=12, 10.3%). The overall postoperative in-hospital fatality rate was 10.3% (12/117). Preoperative use of vasopressors and inotropes, retroperitoneal hematoma, and postoperative abdominal compartment syndrome, gastrointestinal hemorrhage, acute kidney injury, and diffuse intravascular coagulation significantly increased the fatality rate [5/11, 6/24, 5/16, 6/12, 6/17, 23.1%(9/39), 19.6%(9/46), respectively]. Conclusion: The postoperative mortality of rAAA patients is still high in the era of EVAR, especially in patients with preoperative existence of shock and retroperitoneal hematoma, and with postoperative abdominal compartment syndrome, coagulation dysfunction, and acute kidney injury. It is necessary to strengthen perioperative monitoring and management of these patients to reduce the fatality rate.

Asunto(s)

Aneurisma de la Aorta Abdominal , Rotura de la Aorta , Complicaciones Posoperatorias , Humanos , Femenino , Masculino , Aneurisma de la Aorta Abdominal/cirugía , Anciano , Estudios Retrospectivos , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Rotura de la Aorta/cirugía , Pronóstico , Procedimientos Endovasculares , Análisis de Datos

RESUMEN

BACKGROUND: Saccular abdominal aortic aneurysms (AAAs) are considered to be at higher risk of rupture than fusiform AAAs, but not much is known about the extent of this risk. Therefore, this study aimed to compare the rupture presentation between fusiform and saccular AAAs. METHODS AND RESULTS: This is a retrospective cohort study on 27 290 patients who underwent primary endovascular repair for a degenerative AAA between 2016 and 2019, and who were registered in the National Clinical Database in Japan. At operation for nonruptured case, the aneurysm diameter was significantly smaller in saccular AAAs than in fusiform AAAs (median, 44.0 versus 51.0 mm; P<0.001). Similarly, aneurysm diameter at rupture was significantly smaller in saccular AAAs than in fusiform AAAs (median, 55.6 versus 68.0 mm; P<0.001). The likelihood of repair for rupture was significantly higher in saccular AAAs than in fusiform AAAs in the 40- to 54-mm diameter range, in which saccular morphology was found to be an independent risk factor for rupture against fusiform morphology by adjusting for sex and aneurysm diameter (odds ratio, 2.54 [95% CI, 1.75-3.69]). In addition, receiver-operating characteristic curve analysis revealed that the cutoff diameter to predict rupture was smaller in saccular AAAs than in fusiform AAAs (50.5 and 59.5 mm, respectively) based on the Youden index. CONCLUSIONS: Saccular AAAs presented at smaller diameters than fusiform AAAs in patients with ruptured AAAs treated with endovascular aortic repair, which supports the idea that saccular AAAs should be treated at smaller diameters.

Asunto(s)

Aneurisma de la Aorta Abdominal , Rotura de la Aorta , Bases de Datos Factuales , Procedimientos Endovasculares , Humanos , Aneurisma de la Aorta Abdominal/cirugía , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Procedimientos Endovasculares/métodos , Procedimientos Endovasculares/efectos adversos , Femenino , Masculino , Japón/epidemiología , Estudios Retrospectivos , Anciano , Rotura de la Aorta/cirugía , Rotura de la Aorta/diagnóstico por imagen , Factores de Riesgo , Anciano de 80 o más Años , Implantación de Prótesis Vascular , Resultado del Tratamiento , Medición de Riesgo , Persona de Mediana Edad

RESUMEN

OBJECTIVE: Open abdomen therapy (OAT) is commonly used to prevent or treat abdominal compartment syndrome (ACS) in patients with ruptured abdominal aortic aneurysms (rAAAs). This study aimed to evaluate the incidence, treatment, and outcomes of OAT after rAAA from 2006 to 2021. Investigating data on resuscitation fluid, weight gain, and cumulative fluid balance could provide a more systematic approach to determining the timing of safe abdominal closure. METHODS: This was a single centre observational cohort study. The study included all patients treated for rAAA followed by OAT from October 2006 to December 2021. RESULTS: Seventy-two of the 244 patients who underwent surgery for rAAA received OAT. The mean age was 72 ± 7.85 years, and most were male (n = 61, 85%). The most frequent comorbidities were cardiac disease (n = 31, 43%) and hypertension (n = 31, 43%). Fifty-two patients (72%) received prophylactic OAT, and 20 received OAT for ACS (28%). There was a 25% mortality rate in the prophylactic OAT group compared with the 50% mortality in those who received OAT for ACS (p = .042). The 58 (81%) patients who survived until closure had a median of 12 (interquartile range [IQR] 9, 16.5) days of OAT and 5 (IQR 4, 7) dressing changes. There was one case of colocutaneous fistula and two cases of graft infection. All 58 patients underwent successful abdominal closure, with 55 (95%) undergoing delayed primary closure. In hospital survival was 85%. Treatment trends over time showed the increased use of prophylactic OAT (p ≤ .001) and fewer ACS cases (p = .03) assessed by Fisher's exact test. In multivariable regression analysis fluid overload and weight reduction predicted 26% of variability in time to closure. CONCLUSION: Prophylactic OAT after rAAA can be performed safely, with a high rate of delayed primary closure even after long term treatment.

Asunto(s)

Aneurisma de la Aorta Abdominal , Rotura de la Aorta , Hipertensión Intraabdominal , Terapia de Presión Negativa para Heridas , Mallas Quirúrgicas , Humanos , Aneurisma de la Aorta Abdominal/cirugía , Aneurisma de la Aorta Abdominal/mortalidad , Masculino , Anciano , Femenino , Terapia de Presión Negativa para Heridas/efectos adversos , Rotura de la Aorta/cirugía , Rotura de la Aorta/mortalidad , Hipertensión Intraabdominal/etiología , Hipertensión Intraabdominal/prevención & control , Hipertensión Intraabdominal/cirugía , Anciano de 80 o más Años , Resultado del Tratamiento , Estudios Retrospectivos , Tracción/efectos adversos , Tracción/métodos , Factores de Tiempo , Persona de Mediana Edad , Técnicas de Abdomen Abierto/efectos adversos , Factores de Riesgo , Técnicas de Cierre de Herida Abdominal/efectos adversos , Técnicas de Cierre de Herida Abdominal/instrumentación , Fasciotomía/efectos adversos , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/prevención & control , Complicaciones Posoperatorias/epidemiología

Asunto(s)

Rotura de la Aorta , Atrios Cardíacos , Seno Aórtico , Humanos , Seno Aórtico/diagnóstico por imagen , Seno Aórtico/cirugía , Atrios Cardíacos/diagnóstico por imagen , Rotura de la Aorta/diagnóstico por imagen , Rotura de la Aorta/cirugía , Masculino , Aneurisma de la Aorta/diagnóstico por imagen , Aneurisma de la Aorta/cirugía

RESUMEN

Aneurysm of Aortic sinus of Valsalva (ASOV) dissecting into the interventricular septum (IVS) and rupturing into the left ventricle (LV) is a rare clinical diagnosis. Systemic inflammatory diseases like tuberculosis can aggravate this condition. We describe three cases of ASOV dissecting into the IVS and rupturing into the LV. All three patients underwent surgical intervention; two had a successful outcome. A literature review was conducted and19 previously reported cases were studied. The extent and direction of septal dissection determined the associated cardiac valvular and rhythm problems. Patch closure of the mouth of the aneurysm is the surgical method of choice. In the presence of multiple sinus tracts or if there is recurrence after surgical closure, aortic sinus or root replacement techniques have better outcomes.

Asunto(s)

Seno Aórtico , Tabique Interventricular , Humanos , Seno Aórtico/cirugía , Seno Aórtico/diagnóstico por imagen , Masculino , Tabique Interventricular/cirugía , Disección Aórtica/cirugía , Disección Aórtica/complicaciones , Disección Aórtica/diagnóstico , Femenino , Ventrículos Cardíacos/cirugía , Aneurisma de la Aorta/cirugía , Aneurisma de la Aorta/diagnóstico por imagen , Aneurisma de la Aorta/complicaciones , Rotura de la Aorta/cirugía , Rotura de la Aorta/complicaciones , Ecocardiografía , Procedimientos Quirúrgicos Cardíacos/métodos , Niño

RESUMEN

OBJECTIVE: Endovascular aortic repair (EVAR) is a less invasive method than the more physiologically stressful open surgical repair (OSR) for patients with anatomically appropriate abdominal aortic aneurysms (AAAs). Early postoperative outcomes are associated with both patients; physiologic reserve and the physiologic stresses of the surgical intervention. Among frail patients with reduced physiologic reserve, the stress of an aortic rupture in combination with the stress of an operative repair are less well tolerated, raising the risk of complications and mortality. This study aims to evaluate the difference in association between frailty and outcomes among patients undergoing minimally invasive EVAR and the physiologically more stressful OSR for ruptured AAAs (rAAAs). METHODS: Our retrospective cohort study included adults undergoing rAAA repair in the Vascular Quality Initiative from 2010 to 2022. The validated Risk Analysis Index (RAI) (robust, ≤20; normal, 21-29; frail, 30-39; very frail, ≥40) quantified frailty. The association between the primary outcome of 1-year mortality and frailty status as well as repair type were compared using multivariable Cox models generating adjusted hazard ratios (aHRs) with 95% confidence intervals (CIs). Interaction terms evaluated the association's moderation. RESULTS: We identified 5806 patients (age, 72 ± 9 years; 77% male; EVAR, 65%; robust, 6%; normal, 48%; frail, 36%; very, frail 10%) with a 53% observed 1-year mortality rate following rAAA repair. OSR (aHR, 1.43; 95% CI, 1.19-1.73) was associated with increased 1-year mortality when compared with EVAR. Increasing frailty status (frail aHR, 1.26; 95% CI, 1.00-1.59; very frail aHR, 1.64; 95% CI, 1.26-2.13) was associated with increased 1-year mortality, which was moderated by repair type (P-interaction < .05). OSR was associated with increased 1-year mortality in normal (aHR, 1.49; 95% CI, 1.20-1.87) and frail (aHR, 1.51; 95% CI, 1.20-1.89), but not among robust (aHR, 0.88; 95% CI, 0.59-1.32) and very frail (aHR, 1.29; 95% CI, 0.97-1.72) patients. CONCLUSIONS: Frailty and OSR were associated with increased adjusted risk of 1-year mortality following rAAA repair. Among normal and frail patients, OSR was associated with an increased adjusted risk of 1-year mortality when compared with EVAR. However, there was no difference between OSR and EVAR among robust patients who can well tolerate the stress of OSR and among very frail patients who are unable to withstand the surgical stress from rAAA regardless of repair type.

Asunto(s)

Aneurisma de la Aorta Abdominal , Rotura de la Aorta , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Anciano Frágil , Fragilidad , Humanos , Aneurisma de la Aorta Abdominal/cirugía , Aneurisma de la Aorta Abdominal/mortalidad , Aneurisma de la Aorta Abdominal/complicaciones , Masculino , Anciano , Fragilidad/complicaciones , Fragilidad/mortalidad , Fragilidad/diagnóstico , Estudios Retrospectivos , Femenino , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/mortalidad , Rotura de la Aorta/cirugía , Rotura de la Aorta/mortalidad , Rotura de la Aorta/fisiopatología , Factores de Riesgo , Medición de Riesgo , Anciano de 80 o más Años , Resultado del Tratamiento , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/mortalidad , Factores de Tiempo , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/etiología , Persona de Mediana Edad , Estados Unidos/epidemiología , Bases de Datos Factuales

RESUMEN

BACKGROUND: A ruptured thoracoabdominal aortic aneurysm (rTAAA) represents a considerable challenge for surgeons. To date, endovascular procedures have not been able to completely replace open repair when debranching is required. CASE PRESENTATION: A 73-year-old man was admitted to our hospital after complaining of left lateral abdominal pain. Enhanced computed tomography revealed a left retroperitoneal hematoma and a large, ruptured Crawford type IV TAAA. We first performed emergency resuscitative surgery to close the lacerated foramen. A graft replacement was performed 1 month after the initial surgery when the patient had stabilized. At 5 years postoperatively, neither occlusion nor anastomotic pseudoaneurysm was noted on computed tomography. CONCLUSIONS: We provide an update on the perioperative management of patients undergoing open rTAAA repair. This procedure can be considered to ensure complete repair of an rTAAA.

Asunto(s)

Aneurisma Falso , Aneurisma de la Aorta Toracoabdominal , Rotura de la Aorta , Procedimientos Endovasculares , Masculino , Humanos , Anciano , Rotura de la Aorta/diagnóstico por imagen , Rotura de la Aorta/cirugía , Anastomosis Quirúrgica