Predicting risk of rupture and rupture-preventing reinterventions following endovascular abdominal aortic aneurysm repair

BackgroundClinical and imaging surveillance practices following endovascular aneurysm repair (EVAR) for intact abdominal aortic aneurysm (AAA) vary considerably and compliance with recommended lifelong surveillance is poor. The aim of this study was to develop a dynamic prognostic model to enable stratification of patients at risk of future secondary aortic rupture or the need for intervention to prevent rupture (rupture-preventing reintervention) to enable the development of personalized surveillance intervals. MethodsBaseline data and repeat measurements of postoperative aneurysm sac diameter from the EVAR-1 and EVAR-2 trials were used to develop the model, with external validation in a cohort from a single-centre vascular database. Longitudinal mixed-effects models were fitted to trajectories of sac diameter, and model-predicted sac diameter and rate of growth were used in prognostic Cox proportional hazards models. ResultsSome 785 patients from the EVAR trials were included, of whom 155 (197 per cent) experienced at least one rupture or required a rupture-preventing reintervention during follow-up. An increased risk was associated with preoperative AAA size, rate of sac growth and the number of previously detected complications. A prognostic model using predicted sac growth alone had good discrimination at 2years (C-index 068), 3years (C-index 072) and 5years (C-index 075) after operation and had excellent external validation (C-index 076-079). More than 5years after operation, growth rates above 1mm/year had a sensitivity of over 80 per cent and specificity over 50 per cent in identifying events occurring within 2years. ConclusionSecondary sac growth is an important predictor of rupture or rupture-preventing reintervention to enable the development of personalized surveillance intervals. A dynamic prognostic model has the potential to tailor surveillance by identifying a large proportion of patients who may require less intensive follow-up. Potential to tailor surveillancePeer reviewe

Rupture of Abdominal Aortic Aneurysms in Patients Under Screening Age and Elective Repair Threshold

Peer reviewe

International Update on Screening for Abdominal Aortic Aneurysms: Issues and Opportunities

Screening for abdominal aortic aneurysm (AAA) has been shown to be effective at reducing AAA-related mortality and is cost-effective. There are, however, significant variations in AAA screening protocols between healthcare systems and numerous challenges to be overcome. Further evidence of cost- and clinical effectiveness is likely to be required before there is widespread international adoption of AAA screening

International Update on Screening for Abdominal Aortic Aneurysms:Issues and Opportunities

Screening for abdominal aortic aneurysm (AAA) has been shown to be effective at reducing AAA-related mortality and is cost-effective. There are, however, significant variations in AAA screening protocols between healthcare systems and numerous challenges to be overcome. Further evidence of cost- and clinical effectiveness is likely to be required before there is widespread international adoption of AAA screening

Open surgery in endovascular aneurysm repair era: simplified classification in two risk groups owing to factors affecting mortality in 137 ruptured abdominal aortic aneurysms (RAAAs).

Our objective is to identify in 137 true RAAAs operated consecutively in open surgery: (1) diagnostic therapeutic aspects capable of influencing results, (2) risk classes with different prognosis, (3) any situations where the prognosis is so negative that surgery is not recommended. The relationship of 16 anamnestic, clinical and technical parameters prospectively collected with 30-day mortality was retrospectively evaluated by uni- and multivariate analyses. Thirty-day mortality was 37\%. The univariate analysis identified as mortality predictors Hb ≤ 8 g/dl and circulatory shock at hospitalisation, but following the multivariate analysis only circulatory shock was a certainly significant risk-factor. The cumulative effect on mortality of the two parameters identified at univariate analysis translates into a statistically significant difference in mortality between two groups of patients: A (no or just one risk-factor) and B (two risk-factors). To reinstate euvolemia, rather than adequate haemoglobin values, improves the chances of success. A simple prognostic index into two risk classes is feasible, but abstention from surgery is not justified in any type of patient