Editor's Choice - Assessment of International Outcomes of Intact Abdominal Aortic Aneurysm Repair over 9 Years

Background: Case mix and outcomes of complex surgical procedures vary over time and between regions. This study analyses peri-operative mortality after intact abdominal aortic aneurysm (AAA) repair in 11 countries over 9 years. Methods: Data on primary AAA repair from vascular surgery registries in 11 countries for the years 2005-2009 and 2010-2013 were analysed. Multivariate adjusted logistic regression analyses were carried out to adjust for variations in case mix. Results: A total of 83,253 patients were included. Over the two periods, the proportion of patients >= 80 years old increased (18.5% vs. 23.1%; p <.0001) as did the proportion of endovascular repair (EVAR) (44.3% vs. 60.6; p <.0001). In the latter period, 25.8% of AAAs were less than 5.5 cm. The mean annual volume of open repairs per centre decreased from 12.9 to 10.6 between the two periods (p <.0001), and it increased for EVAR from 10.0 to 17.1 (p <.0001). Overall, peri-operative mortality fell from 3.0% to 2.4% (p <.0001). Mortality for EVAR decreased from 1.5% to 1.1% (p <.0001), but the outcome worsened for open repair from 3.9% to 4.4% (p = .008). The peri-operative risk was greater for octogenarians (overall, 3.6% vs. 2.1%, p <.0001; open, 9.5% vs. 3.6%, p <.0001; EVAR, 1.8% vs. 0.7%, p <.0001), and women (overall, 3.8% vs. 2.2%, p <.0001; open, 6.0% vs. 4.0%, p <.0001; EVAR, 1.9% vs. 0.9%, p <.0001). Peri-operative mortality after repair of AAAs Conclusions: In this large international cohort, total peri-operative mortality continues to fall for the treatment of intact AAAs. The number of EVAR procedures now exceeds open procedures. Mortality after EVAR has decreased, but mortality for open operations has increased. The peri-operative mortality for small AM treatment, particularly open surgical repair, is still considerable and should be weighed against the risk of rupture. (C) 2017 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.Peer reviewe

“Medically unexplained” symptoms and symptom disorders in primary care: prognosis-based recognition and classification

Background: Many patients consult their GP because they experience bodily symptoms. In a substantial proportion of cases, the clinical picture does not meet the existing diagnostic criteria for diseases or disorders. This may be because symptoms are recent and evolving or because symptoms are persistent but, either by their character or the negative results of clinical investigation cannot be attributed to disease: so-called “medically unexplained symptoms” (MUS). MUS are inconsistently recognised, diagnosed and managed in primary care. The specialist classification systems for MUS pose several problems in a primary care setting. The systems generally require great certainty about presence or absence of physical disease, they tend to be mind-body dualistic, and they view symptoms from a narrow specialty determined perspective. We need a new classification of MUS in primary care; a classification that better supports clinical decision-making, creates clearer communication and provides scientific underpinning of research to ensure effective interventions. Discussion: We propose a classification of symptoms that places greater emphasis on prognostic factors. Prognosis-based classification aims to categorise the patient’s risk of ongoing symptoms, complications, increased healthcare use or disability because of the symptoms. Current evidence suggests several factors which may be used: symptom characteristics such as: number, multi-system pattern, frequency, severity. Other factors are: concurrent mental disorders, psychological features and demographic data. We discuss how these characteristics may be used to classify symptoms into three groups: self-limiting symptoms, recurrent and persistent symptoms, and symptom disorders. The middle group is especially relevant in primary care; as these patients generally have reduced quality of life but often go unrecognised and are at risk of iatrogenic harm. The presented characteristics do not contain immediately obvious cut-points, and the assessment of prognosis depends on a combination of several factors. Conclusion: Three criteria (multiple symptoms, multiple systems, multiple times) may support the classification into good, intermediate and poor prognosis when dealing with symptoms in primary care. The proposed new classification specifically targets the patient population in primary care and may provide a rational framework for decision-making in clinical practice and for epidemiologic and clinical research of symptoms

Peri-Operative Management of Patients Undergoing Fenestrated-Branched Endovascular Repair for Juxtarenal, Pararenal and Thoracoabdominal Aortic Aneurysms: Preventing, Recognizing and Treating Complications to Improve Clinical Outcomes

The advent and refinement of complex endovascular techniques in the last two decades has revolutionized the field of vascular surgery. This has allowed an effective minimally invasive treatment of extensive disease involving the pararenal and the thoracoabdominal aorta. Fenestrated-branched EVAR (F/BEVAR) now represents a feasible technical solution to address these complex diseases, moving the proximal sealing zone above the renal-visceral vessels take-off and preserving their patency. The aim of this paper was to provide a narrative review on the peri-operative management of patients undergoing F/BEVAR procedures for juxtarenal abdominal aortic aneurysm (JAAA), pararenal abdominal aortic aneurysm (PRAA) or thoracoabdominal aortic aneurism (TAAA). It will focus on how to prevent, diagnose, and manage the complications ensuing from these complex interventions, in order to improve clinical outcomes. Indeed, F/BEVAR remains a technically, physiologically, and mentally demanding procedure. Intraoperative adverse events often require prolonged or additional procedures and complications may significantly impact a patient’s quality of life, health status, and overall cost of care. The presence of standardized preoperative, perioperative, and postoperative pathways of care, together with surgeons and teams with significant experience in aortic surgery, should be considered as crucial points to improve clinical outcomes. Aggressive prevention, prompt diagnosis and timely rescue of any major adverse events following the procedure remain paramount clinical needs

Editor's Choice - Infective Native Aortic Aneurysms: A Delphi Consensus Document on Terminology, Definition, Classification, Diagnosis, and Reporting Standards.

There is no consensus regarding the terminology, definition, classification, diagnostic criteria, and algorithm, or reporting standards for the disease of infective native aortic aneurysm (INAA), previously known as mycotic aneurysm. The aim of this study was to establish this by performing a consensus study. The Delphi methodology was used. Thirty-seven international experts were invited via mail to participate. Four two week Delphi rounds were performed, using an online questionnaire, initially with 22 statements and nine reporting items. The panellists rated the statements on a five point Likert scale. Comments on statements were analysed, statements revised, and results presented in iterative rounds. Consensus was defined as ≥ 75% of the panel selecting "strongly agree" or "agree" on the Likert scale, and consensus on the final assessment was defined as Cronbach's alpha coefficient &gt; .80. All 38 panellists completed all four rounds, resulting in 100% participation and agreement that this study was necessary, and the term INAA was agreed to be optimal. Three more statements were added based on the results and comments of the panel, resulting in a final 25 statements and nine reporting items. All 25 statements reached an agreement of ≥ 87%, and all nine reporting items reached an agreement of 100%. The Cronbach's alpha increased for each consecutive round (round 1 = .84, round 2 = .87, round 3 = .90, and round 4 = .92). Thus, consensus was reached for all statements and reporting items. This Delphi study established the first consensus document on INAA regarding terminology, definition, classification, diagnostic criteria, and algorithm, as well as reporting standards. The results of this study create essential conditions for scientific research on this disease. The presented consensus will need future amendments in accordance with newly acquired knowledge

Body Mass Index and Operating Times in Vascular Procedures

: Introduction: The influence of body mass index (BMI) on operating times in central and peripheral vascular surgical procedures was investigated. Report: A national cohort of Danish patients who underwent a vascular procedure between 1983 and 2012 was used for analysis. Data were analysed with pairwise comparisons of BMI groups for operating times using the independent samples Kruskall–Wallis test. Discussion: A total of 3,255 carotid endarterectomies; 6,885 central vascular procedures; and 4,488 peripheral bypasses were included for the analysis. Median operating times for carotid endarterectomy and central vascular procedures were, respectively, 5 and 15 minutes longer in obese patients than in normal weight patients. This represents a 7% and 10% increase in median operating times, respectively. Linear and multi-adjusted linear regressions were conducted adjusting for confounders, showing a significant correlation between BMI and operating time. Obesity significantly increased the operating times in carotid endarterectomy and central vascular procedures. These may have ramifications for the individual operative stress but not necessarily on logistical operation planning. Keywords: Body mass index (BMI), Obesity, Operating time, Surgery, Vascular surgical procedure

Male Sex Associated with Increased Long-term Cardiovascular Mortality after Peripheral Vascular Surgery for Atherosclerosis Despite Optimal Medical Treatment

BackgroundThe cardiovascular burden and consequences of peripheral atherosclerosis appear to differ between men and women. Data regarding long-term outcomes, including the impact of medical prophylactic treatment, are insufficient. This study examined long-term outcomes according to sex following primary vascular surgery, adjusted for multiple variables as well as recommended medical prophylaxis.MethodsAll Danish patients who underwent peripheral vascular surgery from January 2000 to December 2007 were stratified into five procedural groups: (a) aorto-iliac bypass or thromboendarterectomy, (b) femoro–femoral crossover, (c) thromboendarterectomy of the femoral arteries, (d) infrainguinal bypass, or (e) axillo- uni-, and bifemoral bypass. Data were analyzed according to sex for differences in myocardial infarction, stroke, and death, individually and combined, after surgery.ResultsA total of 11,234 patients were included: 6,289 males and 4,945 females. The overall adjusted hazard ratio for male patients compared with female patients for death was 1.11 (95% CI 1.06–1.17), for MI was 1.16 (95% CI 1.04–1.29), for stroke was 0.99 (95% CI 0.89–1.11), and for any major adverse cardiovascular event was 1.10 (95% CI 1.05–1.16).ConclusionsThese findings show that, despite indication, severity, and concomitant medical treatment of peripheral artery disease, men have a higher risk of mortality and adverse cardiovascular events following surgery for peripheral arterial disease

Comparison of Early and Mid-Term Outcomes After Fenestrated-Branched Endovascular Aortic Repair in Patients With or Without Prior Infrarenal Repair

Objective: The purpose of this study was to compare short- and mid-term outcomes of fenestrated-branched endovascular repair (F-BEVAR) of pararenal (PRAA)/thoracoabdominal (TAAA) aortic aneurysms in patients with or without prior endovascular/open (EVAR/OAR) infrarenal aortic repair. Methods: Data from consecutive F-BEVAR (2010–2019) at two high-volume aortic centers were retrospectively reviewed. Primary endpoints were technical success, 30-day mortality, and overall survival. Secondary endpoints included 30-day major adverse events (MAE), freedom from type I/III endoleaks, reinterventions, sac expansion, and target vessel (TV) primary patency. Results: A total of 222 consecutive patients were included for analysis; of these 58 (26.1%) had prior infrarenal repair (EVAR=33, OAR=25) and 164 (73.9%) had native PRAA/TAAA. At baseline, patients with prior infrarenal repair were older (mean age=75.1 vs 71.6 years, p=.005) and the proportion of females was lower (8.6% vs 29.3%, p=.002). Technical success was 97.8% (n=217) in the entire cohort, without any significant differences between study groups (94.8% vs 98.8%, p=.08). At 30 days, there were no significant differences between patients with prior infrarenal repair as compared with those without in rate of MAE (44.8% vs 54.9%, p=.59). The 5-year estimate of survival for those who underwent native aortic repair was 61.6%, versus 61.3% for those who had a previous repair (p=.67). The 5-year freedom from endoleaks I/III estimates were significantly lower in patients who had prior infrarenal repair as compared with patients undergoing treatment of native aneurysms (57.1% vs 66.1%, p=.03), mainly owing to TV-related endoleaks (ie, type IC and/or IIIC endoleaks). No significant differences were found between study groups in rates of reinterventions and TV primary patency. Five-year estimates of freedom from sac increase >5mm were significantly lower in patients who received F-BEVAR after previous infrarenal repair as compared with those who underwent treatment of native aneurysms (48.6% vs 77.5%, p=.002). Conclusions: F-BEVAR is equally safe and feasible for treatment of patients with prior infrarenal repair as compared with those undergoing treatment for native aneurysms. Increased rates of TV-related endoleaks were observed which could lead to lower freedom from aneurysm sac shrinkage during follow-up. Nevertheless, the 5-year rates of reinterventions and TV patency were similar, thereby indicating that overall effectiveness of treatment remained satisfactory at mid-term

A Delphi Consensus on Patient Reported Outcomes for Registries and Trials Including Patients with Intermittent Claudication : Recommendations and Reporting Standard

Objective: This study aimed to develop a core set of patient reported outcome quality indicators (QIs) for the treatment of patients with intermittent claudication (IC), that allow a broad international implementation across different vascular registries and within trials. Methods: A rigorous modified two stage Delphi technique was used to promote consensus building on patient reported outcome QIs among an expert panel consisting of international vascular specialists, patient representatives, and registry members of the VASCUNET and the International Consortium of Vascular Registries. Potential QIs identified through an extensive literature search or additionally proposed by the panel were validated by the experts in a preliminary survey and included for evaluation. Consensus was reached if &gt;= 80% of participants agreed that an item was both clinically relevant and practical. Results: Participation rates in two Delphi rounds were 66% (31 participants of 47 invited) and 90% (54 of 60), respectively. Initially, 145 patient reported outcome QIs were documented. Following the two Delphi rounds, 18 quality indicators remained, all of which reached consensus regarding clinical relevance. The VascuQoL questionnaire (VascuQoL-6), currently the most common patient reported outcome measurement (PROM) used within vascular registries, includes a total of six items. Five of these six items also matched with high rated indicators identified in the Delphi study. Consequently, the panel recommends the use of the VascuQoL-6 survey as a preferred core PROM QI set as well as an optional extension of 12 additional patient reported QIs that were also identified in this study. Conclusion: The current recommendation based on the Delphi consensus building approach, strengthens the international harmonisation of registry data collection in relation to patient reported outcome quality. Continuous and standardised quality assurance will ensure that registry data may be used for future quality benchmarking studies and, ultimately, positively impact the overall quality of care provided to patients with peripheral arterial occlusive disease