Risk factors influencing outcome of endovascular abdominal aortic aneurysm repair

Contains fulltext : 29854.pdf (publisher's version ) (Open Access)Abdominal Aortic Aneurysm (AAA) is a vascular disorder in which the abdominal aorta becomes permanently dilated to at least 1.5 times its normal diameter. The prevalence of AAA has increased rapidly during the last decade, and aneurysmal rupture is now the 13th most common cause of death in the Western world. Endovascular treatment of abdominal aortic aneurysms, introduced at the beginning of the 1990s, was a significant accomplishment in vascular surgery. In this PhD-thesis we analysed the effect of patient-related characteristics, device brands, aorto-iliac morphology, and follow-up strategy, on the outcomes after endovascular abdominal aortic aneurysm repair (EVAR). Our study revealed that although patients with diabetes mellitus had a higher 30-day mortality rate, long-term survival was similar to patients without diabetes. We also supported the proposition that EVAR may be considered when treating octogenarians since the risk for late complications, compared with open repair, may be outweighed by the lower early mortality and the shorter time for physical recovery. We also concluded that preoperative statin use was independently associated with improved overall-survival after EVAR. When analysing the different stent-graft brands, no single make of stent-graft emerged as the best. However, it was reassuring to note that the later models of stent-grafts performed better than the first generation commercially available versions. In our study assessing the influence of the infra-renal neck anatomy, we concluded that to obtain optimal results with EVAR, the accepted criteria of the infra-renal neck dimensions should be adhered to. With regard to the surveillance intensity, further assessment is indicated to evaluate the effectiveness of different frequencies of follow-up visits. From this thesis we may conclude that a range of different aspects can influence the outcomes after EVAR. These findings emphasize the importance of proper patient selection to obtain optimal results after endovascular aneurysm repairRU Radboud Universiteit Nijmegen, 22 november 2006Promotor : Blankensteijn, J.D. Co-promotores : Buth, J., Laheij, R.J.F.224 p

Influence of diabetes mellitus on the endovascular treatment of abdominal aortic aneurysms.

Contains fulltext : 48032.pdf (publisher's version ) (Open Access)PURPOSE: To investigate the influence of diabetes mellitus on outcome after endovascular abdominal aortic aneurysm (AAA) repair. METHODS: Of 6017 patients enrolled in the EUROSTAR registry after undergoing endovascular AAA repair between May 1994 and December 2003, 731 (12%) had diabetes mellitus (690 men; mean age 72 years, range 37-100). Patient demographics, risk factors, aneurysm morphology, operative and procedural details, complications, major events, and regular follow-up information were compared. The relationships of complications and events to diabetes mellitus, which were tested with multivariate logistic regression analysis and Cox proportional hazards modeling, are expressed as odds ratios (OR) and hazard rates (HR) with 95% confidence intervals (CI). Survival was compared with life-table analysis. Results : A significantly higher risk of device-related complications was observed in diabetic patients (8% versus 6%, p < 0.049; OR 1.35, 95% CI 1.00 to 1.82). The greatest difference in the groups was in mortality, which was significantly higher in the diabetic population (13%) compared to the nondiabetic patients (10%, p < 0.039; OR 1.27, 95% CI 1.01 to 1.59). Deaths, which occurred at a higher frequency within the 30-day perioperative period in diabetic patients, were primary due to cardiac complications. Insulin-controlled type 2 diabetic patients had significantly lower rates of early and late endoleaks and secondary interventions than diet-controlled type 2 diabetics (p = 0.002, p = 0.0001, and p = 0.0008, respectively) and nondiabetic patients (p = 0.002, p = 0.0005, and p = 0.0025, respectively). The cumulative survival after 48 months did not differ significantly: 74% in diabetics and 79% in the population without diabetes. CONCLUSIONS: Patients with diabetes mellitus had a significantly higher early mortality rate after EVAR, but their long-term survival was similar to nondiabetic patients

What determines and are the consequences of surveillance intensity after endovascular abdominal aortic aneurysm repair?

Contains fulltext : 47930.pdf (publisher's version ) (Closed access)Follow-up examinations are advised 1, 3, 6, 12, 18, and 24 months and yearly thereafter by the European Collaborating Group on Stent-Graft Techniques for Abdominal Aortic Aneurysm Repair (EUROSTAR). The aim of this study was to evaluate the determinants and consequences of surveillance completeness. Patients who underwent endovascular abdominal aortic aneurysm repair between October 1996 and August 2004 and enrolled in the EUROSTAR registry were analyzed. Two groups were compared: patients who attended all scheduled visits (group A) and those who came infrequently (group B). Odds ratios and hazard rates (HRs) with 95% confidence intervals (CIs) were determined to detect which patient characteristics and complications were associated with follow-up intensity. Of the 4,433 patients, 1,538 (35%) attended all scheduled visits until the end of follow-up (group A). Analysis of patient characteristics demonstrated that intensive visitors were more often smokers, hyperlipemic, and considered unfit for open surgery or general anesthesia. Complications during follow-up, including endoleaks (24% vs. 20%), kinking (3.5% vs. 2.5%), and migration (4.9% vs. 3.5%), appeared significantly more frequently in group A. Despite intensive follow-up of this category, still a greater proportion died (12% vs. 9%, adjusted HR = 1.5, 95% CI 1.2-1.8). After 84 months of follow-up, the cumulative survival rates in groups A and B were 71% and 74%, respectively (p < 0.0001). It seems that follow-up intensity was based on baseline patient characteristics. High-risk patients had, despite more intensive surveillance, still more complications after adjustment for patient, morphological, and center-specific characteristics. Further assessment is indicated to evaluate the effectiveness of different frequencies of surveillance visits

What determines and are the consequences of surveillance intensity after endovascular abdominal aortic aneurysm repair?

Contains fulltext : 47930.pdf (publisher's version ) (Closed access)Follow-up examinations are advised 1, 3, 6, 12, 18, and 24 months and yearly thereafter by the European Collaborating Group on Stent-Graft Techniques for Abdominal Aortic Aneurysm Repair (EUROSTAR). The aim of this study was to evaluate the determinants and consequences of surveillance completeness. Patients who underwent endovascular abdominal aortic aneurysm repair between October 1996 and August 2004 and enrolled in the EUROSTAR registry were analyzed. Two groups were compared: patients who attended all scheduled visits (group A) and those who came infrequently (group B). Odds ratios and hazard rates (HRs) with 95% confidence intervals (CIs) were determined to detect which patient characteristics and complications were associated with follow-up intensity. Of the 4,433 patients, 1,538 (35%) attended all scheduled visits until the end of follow-up (group A). Analysis of patient characteristics demonstrated that intensive visitors were more often smokers, hyperlipemic, and considered unfit for open surgery or general anesthesia. Complications during follow-up, including endoleaks (24% vs. 20%), kinking (3.5% vs. 2.5%), and migration (4.9% vs. 3.5%), appeared significantly more frequently in group A. Despite intensive follow-up of this category, still a greater proportion died (12% vs. 9%, adjusted HR = 1.5, 95% CI 1.2-1.8). After 84 months of follow-up, the cumulative survival rates in groups A and B were 71% and 74%, respectively (p < 0.0001). It seems that follow-up intensity was based on baseline patient characteristics. High-risk patients had, despite more intensive surveillance, still more complications after adjustment for patient, morphological, and center-specific characteristics. Further assessment is indicated to evaluate the effectiveness of different frequencies of surveillance visits

Long-term results of endovascular abdominal aortic aneurysm treatment with the first generation of commercially available stent grafts.

Contains fulltext : 53219.pdf (publisher's version ) (Closed access)HYPOTHESIS: Little information about the long-term results of endovascular abdominal aortic aneurysm repair is available. This study was performed to evaluate the long-term data of patients treated with the first generation of commercially available stent grafts. DESIGN: Multicenter registry. SETTING: Sixty-two European centers that participated in the EUROSTAR (EUROpean collaborators on Stent-graft Techniques for abdominal aortic Aneurysm Repair) registry. PATIENTS: A total of 1190 patients with a follow-up of up to 8 years, who underwent endovascular abdominal aortic aneurysm repair with a stent graft (Stentor or Vanguard). INTERVENTION: Elective endovascular abdominal aortic aneurysm repair. MAIN OUTCOME MEASURES: The morbidity and mortality data of patients treated with the first-generation stent graft who enrolled in the EUROSTAR registry were analyzed. Incidence rates of complications were calculated to quantify annual risks. Life-table analyses and multivariate Cox proportional hazards models were used for the survival analysis. RESULTS: Conversion to open repair, aneurysm rupture, all-cause death, and aneurysm-related death occurred in 7.1%, 2.4%, 19.9%, and 3.0% of the patients, respectively. The cumulative percentage of the combined outcome event, conversion-free and rupture-free survival, after 8 years was 48.0%. Procedure-related complications that frequently occurred were endoleak (13.0 cases per 100 patient-years), stenosis/thrombosis (4.6 cases per 100 patient-years), and stent migration (4.3 cases per 100 patient-years). CONCLUSIONS: Patients treated with the first generation of stent grafts will need lifelong surveillance because of a considerable risk of late complications. How these findings translate to the outcome of newer-generation stent grafts is unknown. For this reason, vigilant surveillance remains indicated in all patients who undergo endovascular abdominal aortic aneurysm repair

Risk-adjusted outcome analysis of endovascular abdominal aortic aneurysm repair in a large population: how do stent-grafts compare?

Contains fulltext : 48510.pdf (publisher's version ) (Open Access)PURPOSE: To compare differences in the applicability and incidence of postoperative adverse events among stent-grafts used for repair of infrarenal aortic aneurysms. METHODS: An analysis of 6787 patients from the EUROSTAR Registry database was conducted to compare aneurysm morphological features, patient characteristics, and postoperative events for the AneuRx, EVT/Ancure, Excluder, Stentor, Talent, and Zenith devices versus the Vanguard device (control) and each other. Annual incidence rates of complications were determined, and risks were compared using the Cox proportional hazards analysis. RESULTS: The annual incidence rates were: device-related endoleak (types I and III) 6% (range 4%-10%), type II endoleak 5% (range 0.3%-11%), migration 3% (range 0.5%-5%), kinking 2% (range 1%-5%), occlusion 3% (range 1%-5%), rupture 0.5% (range 0%-1%), and all-cause mortality 7% (range 5%-8%). After adjustment for factors influencing outcome, AneuRx, Excluder, Talent, and Zenith devices were associated with a lower risk of migration, kinking, occlusion, and secondary intervention compared to the Vanguard device. Significant increased risk for conversion (EVT/Ancure) and reduced risk of aneurysm rupture (AneuRx and Zenith) and all-cause mortality (Excluder) were found compared to the Vanguard device. CONCLUSIONS: Significant differences exist between stent-grafts of different labels in terms of applicability and complications during intermediate to long-term follow-up. Since each stent-graft has its drawbacks, no single label can be identified as the best. It is reassuring that developments in stent-grafts indeed result in better performance than the early stent-grafts. However, a single device incorporating all the perceived improvements should still be pursued

Procedure-related mortality of endovascular abdominal aortic aneurysm repair using revised reporting standards.,Mortalidade relacionada ao tratamento endovascular do aneurisma da aorta abdominal com o uso dos modelos revisados

Contains fulltext : 53262.pdf (publisher's version ) (Open Access)OBJECTIVE: The aim of this study was to evaluate the definition of Procedure-related mortality after endovascular aneurysm repair (EVAR) as defined by the Committee for Standardized Reporting Practices in Vascular Surgery. METHODS: Data on patients with an AAA were taken from the EUROSTAR database. The patients underwent EVAR between June 1996 and February 2004 and were analyzed retrospectively. Explicit probability of cause of death was recorded. The time interval from operation, hospital discharge or second interventions till death was recorded. RESULTS: A total of 589 out of 5612 patients (10.5%) died after EVAR in total follow up and all causes of death were included. 141 (2.5%) patients died due to aneurysms reported after the EVAR procedure of which 28 (4.8%) were ruptures, 25 (4.2%) graft-infections and 88 (14.9%) patients who died within 30 days after the initial procedure (present definition, also known as short term clinical outcome). In addition 25 patients died after 30 days, but were then (at moment of death) still in the hospital, or were transferred to a nursing home for further re-evaluation, or needed second interventions. Taking into account the duration of hospitalization and mortality immediately after procedure-related second interventions, 49 delayed deaths might also be regarded as being EVAR procedure-related. CONCLUSION: Delayed deaths are a considerable proportion of procedure-related deaths after EVAR within the revised time frame

Relationship between tap water hardness, magnesium, and calcium concentration and mortality due to ischemic heart disease or stroke in the Netherlands

BACKGROUND: Conflicting results on the relationship between the hardness of drinking water and mortality related to ischemic heart disease (IHD) or stroke have been reported. OBJECTIVES: We investigated the possible association between tap water calcium or magnesium concentration and total hardness and IHD mortality or stroke mortality. METHODS: In 1986, a cohort of 120,852 men and women aged 55-69 years provided detailed information on dietary and other lifestyle habits. Follow-up for mortality until 1996 was established by linking data from the Central Bureau of Genealogy and Statistics Netherlands. We calculated tap water hardness for each postal code using information obtained from all pumping stations in the Netherlands. Tap water hardness was categorized as soft [3), and hard (> 2.0 mmol/L CaCO3). The multivariate case-cohort analysis was based on 1,944 IHD mortality and 779 stroke mortality cases and 4,114 subcohort members. RESULTS: For both men and women, we observed no relationship between tap water hardness and IHD mortality [hard vs. soft water: hazard ratio (HR) = 1.03; 95% confidence interval (CI), 0.85-1.28 for men and HR = 0.93; 95% CI, 0.71-1.21 for women) and stroke mortality (hard vs. soft water HR = 0.90; 95% CI, 0.66-1.21 and HR = 0.86; 95% CI, 0.62-1.20, respectively). For men with the 20% lowest dietary magnesium intake, an inverse association was observed between tap water magnesium intake and stroke mortality (HR per 1 mg/L intake = 0.75; 95% CI, 0.61-0.91), whereas for women with the 20% lowest dietary magnesium intake, the opposite was observed. CONCLUSIONS: We found no evidence for an overall significant association between tap water hardness, magnesium or calcium concentrations, and IHD mortality or stroke mortality. More research is needed to investigate the effect of tap water magnesium on IHD mortality or stroke mortality in subjects with low dietary magnesium intake

Fluid intake and colorectal cancer risk in the Netherlands cohort study

Total fluid intake, specifically water intake, has been suggested to protect against colorectal cancer. We examined the association of total fluid intake with colorectal cancer endpoints and possible effect modification by fiber intake within the Netherlands Cohort Study (N = 120,852). We also investigated intake of specific beverages. After 13.3 yr, 1,443 male and 1,040 female colorectal cancer cases with complete baseline questionnaires were available for case-cohort analyses. Multivariate analyses showed no dose-response relationship of total fluid intake and intake of specific beverages with the risk of overall colorectal, proximal, and distal colon cancer. For rectal cancer risk in men, there was a nonsignificant positive trend for total fluid intake [>1,500 vs. =1,000 ml/day: HR = 1.50, 95% CI = 0.95-2.37, P trend = 0.08) and a significant positive trend for coffee intake (>6 vs. =2 cups/day: HR = 1.60, 95% CI = 0.96-2.66, P trend = 0.05). However, a nonsignificant positive trend for total fluid intake was no longer observed when additionally adjusting for coffee intake. Tests for interaction were not significant. In conclusion, total fluid intake was not associated with colorectal cancer risk in either men or women. There was no evidence that fiber intake modified associations. Of the specific beverages, coffee intake was positively associated with rectal cancer risk in men. Copyright © 2010, Taylor & Francis Group, LLC