Hospital Incidence, Treatment, and Outcome of 885 Patients with Thoracoabdominal Aortic Aneurysms Treated in Switzerland over 10 Years-A Secondary Analysis of Swiss DRG Data

Despite the development of fenestrated and branched endovascular aortic repair (f/bEVAR), the surgical management of thoraco-abdominal aortic aneurysms (TAAAs) remains a major challenge. The aim of this study was to analyse the hospital incidence and hospital mortality of patients treated for TAAAs in Switzerland. Secondary data analysis was performed using nationwide administrative discharge data from 2009-2018. Standardised incidence rates and adjusted mortality rates were calculated. A total of 885 cases were identified (83.2% nonruptured (nrTAAA), 16.8% ruptured (rTAAA)), where 69.3% were male. The hospital incidence rate for nrTAAA was 0.4 per 100,000 women and 0.9 per 100,000 men in 2009, which had doubled for both sexes by 2018. For rTAAA, there was no trend over the years. The most common procedure was f/bEVAR (44.2%), followed by OAR (39.5%), and 9.8% received a hybrid procedure. There was a significant increase in endovascular procedures over time. The all-cause mortality was 7.1% with nrTAAA and 55% with rTAAA. The mortality was lower for rTAAA when f/bEVAR or hybrid procedures were used. A ruptured aneurysm and higher comorbidity were associated with higher hospital mortality. This study demonstrates that the treatment approach has changed significantly over the observed period. The use of f/bEVAR nearly tripled in nrTAAA and doubled in rTAAA during this decade

Preventing Lower Limb Graft Thrombosis after Infrainguinal Arterial Bypass Surgery with Antithrombotic Agents (PATENT Study): An International Expert Based Delphi Consensus

(1) Background: High-level evidence on antithrombotic therapy after infrainguinal arterial bypass surgery in specific clinical scenarios is lacking. (2) Methods: A modified Delphi procedure was used to develop consensus statements. Experts voted on antithrombotic treatment regimens for three types of infrainguinal arterial bypass procedures: above-the-knee popliteal artery; below-the-knee popliteal artery; and distal, using vein, prosthetic, or biological grafts. The treatment regimens for these nine procedures were then voted on in three clinical scenarios: isolated PAOD, atrial fibrillation, and recent coronary intervention. (3) Results: The survey was conducted with 28 experts from 15 European countries, resulting in consensus statements on 25/27 scenarios. Experts recommended single antiplatelet therapy after above-the-knee popliteal artery bypasses regardless of the graft material used. For below-the-knee popliteal artery bypasses, experts suggested combining single antiplatelet therapy with low-dose rivaroxaban if the graft material used was autologous or biological. They did not recommend switching to triple therapy for patients on oral anticoagulants for atrial fibrillation or dual antiplatelet therapy in any scenario. (4) Conclusions: Great inconsistency in the antithrombotic therapy administered was found in this study. This consensus offers guidance for scenarios that are not covered in the current ESVS guidelines but must be interpreted within its limitations

Prognostic model for survival of patients with abdominal aortic aneurysms treated with endovascular aneurysm repair.

The role of endovascular aneurysm repair (EVAR) in patients with asymptomatic abdominal aortic aneurysm (AAA) who are unfit for open surgical repair has been questioned. The impending risk of aneurysm rupture, the risk of elective repair, and the life expectancy must be balanced when considering elective AAA repair. This retrospective observational cohort study included all consecutive patients treated with standard EVAR for AAA at a referral centre between 2001 and 2020. A previously published predictive model for survival after EVAR in patients treated between 2001 and 2012 was temporally validated using patients treated at the same institution between 2013 and 2020 and updated using the overall cohort. 558 patients (91.2% males, mean age 74.9 years) were included. Older age, lower eGFR, and COPD were independent predictors for impaired survival. A risk score showed good discrimination between four risk groups (Harrel's C = 0.70). The 5-years survival probabilities were only 40% in "high-risk" patients, 68% in "moderate-to-high-risk" patients, 83% in "low-to-moderate-risk", and 89% in "low-risk" patients. Low-risk patients with a favourable life expectancy are likely to benefit from EVAR, while high-risk patients with a short life expectancy may not benefit from EVAR at the current diameter threshold

Airway management in a Helicopter Emergency Medical Service (HEMS): a retrospective observational study of 365 out-of-hospital intubations.

BACKGROUND Airway management is a key skill in any helicopter emergency medical service (HEMS). Intubation is successful less often than in the hospital, and alternative forms of airway management are more often needed. METHODS Retrospective observational cohort study in an anaesthesiologist-staffed HEMS in Switzerland. Patient charts were analysed for all calls to the scene (n = 9,035) taking place between June 2016 and May 2017 (12 months). The primary outcome parameter was intubation success rate. Secondary parameters included the number of alternative techniques that eventually secured the airway, and comparison of patients with and without difficulties in airway management. RESULTS A total of 365 patients receiving invasive ventilatory support were identified. Difficulties in airway management occurred in 26 patients (7.1%). Severe traumatic brain injury was the most common indication for out-of-hospital Intubation (n = 130, 36%). Airway management was performed by 129 different Rega physicians and 47 different Rega paramedics. Paramedics were involved in out-of-hospital airway manoeuvres significantly more often than physicians: median 7 (IQR 4 to 9) versus 2 (IQR 1 to 4), p < 0.001. CONCLUSION Despite high overall success rates for endotracheal intubation in the physician-staffed service, individual physicians get only limited real-life experience with advanced airway management in the field. This highlights the importance of solid basic competence in a discipline such as anaesthesiology

Long-Term Outcomes in Thoracic Endovascular Aortic Repair for Complicated Type B Aortic Dissection or Intramural Hematoma Depending on Proximal Landing Zone

Thoracic endovascular aortic repair (TEVAR) is the preferred treatment for complicated type B aortic dissection (TBAD) or intramural hematoma (IMH). This study aimed to investigate the association of the proximal landing zone and its morphology with long-term outcomes in patients with TBAD or IMH. A total of 94 patients who underwent TEVAR for TBAD or IMH between 10/2003 and 01/2020 were included. The cohort was divided according to the proximal landing in Ishimaru zone 2 or 3 and the presence of a healthy landing zone (HLZ; non-dissected or aneurysmatic, ≥2 cm length). Primary outcome was freedom from aortic reintervention. Secondary endpoints were freedom from aortic growth, stroke, spinal cord ischemia, retrograde dissection, proximal stent-graft induced new entry (pSINE), debranching failure, and mortality. Outcomes were assessed using Cox proportional hazard models with mortality as a competing risk. A proximal TEVAR landing in zone 2 was associated with higher rates of reinterventions compared to zone 3 (33% vs. 15%, p = 0.031), spinal cord ischemia (8% vs. 0%, p = 0.037), and pSINE (13% vs. 2%, p = 0.032). No difference was found for the other outcomes, including mortality. Landing in dissected segments was not associated with impaired results. Proximal TEVAR landing in zone 3 may be preferable with regard to long-term aortic reintervention in patients with TBAD or IMH

Inter-hospital transfer of patients with ruptured abdominal aortic aneurysm in Switzerland

Objectives: To analyse the association of inter-hospital transfer on hospital mortality in patients with ruptured abdominal aortic aneurysms (rAAA) in Switzerland. Design: Secondary data analysis of case-related hospital discharge data from the Swiss Federal Statistical Office for the years 2009-2018. All cases with rAAA as primary or secondary diagnosis were included. Cases with rAAA as a secondary diagnosis without surgical treatment and cases that had been transferred to another hospital without surgical treatment at the referring hospital were excluded. Methods: Logistic regression models for hospital mortality were constructed with age, sex, type of admission, van Walraven comorbidity score, type of treatment, insurance class, hospital level, and year of treatment as independent variables. Results: From 1 January 2009 to 31 December 2018, 1798 cases with rAAA were treated either surgically (62.5%) or palliatively (37.5%) in Switzerland. 72.9% of the cases were directly treated (surgically or palliative) at the hospital of first presentation, whereas 27.1% of all cases with rAAA were transferred between hospitals. The overall crude hospital mortality was 50.3%; in the surgically treated cohort it was 23.1%, in the palliative treated cohort it was 95.7%.Inter-hospital transfer was associated with better survival compared to patients directly admitted (OR 0.52, 95%-CI: 0.36-0.75, p<.001). Treatment in major hospitals was associated with a significantly higher mortality compared to treatment in university hospitals (OR 1.98, 1.41-2.79, p<.001). There was no evidence for an association of open repair with hospital mortality, OR 1.06, 0.77-1.48, p=.722, compared to endovascular repair. Conclusions: In a healthcare system such as Switzerland with a highly specialised rescue chain, transfer of haemodynamically stable patients with rAAA is probably safe. In this setting, a centralised medical care might outweigh the potential disadvantages of a limited delay due to patient transfer. Further studies are needed to address potential confounding factors such as hemodynamic and anatomical features. Keywords: "DRG"; "aortic aneurysm; "aortic rupture"; "patient transfer"; "secondary data analysis"; abdominal"

Hospital incidence and mortality of patients treated for abdominal aortic aneurysms in Switzerland - a secondary analysis of Swiss DRG statistics data

AIM OF THE STUDY To analyse hospital incidence and in-hospital mortality of patients treated for abdominal aortic aneurysms in Switzerland. METHODS Secondary data analysis of case-related hospital discharge data of the Swiss Federal Statistical Office for the years 2009-2018. Patients who were hospitalised and surgically treated for nonruptured abdominal aortic aneurysms or hospitalised and treated for ruptured abdominal aortic aneurysms were included in the analysis. Standardised annual incidences rates were calculated using the European standard population 2013. In-hospital all-cause mortality rates were calculated as raw values and standardised for age, sex, and the van Walraven comorbidity score. RESULTS A total of 10,728 cases were included in this study, of which 87.1% were male. Overall, 22.7% of the patients presented with a ruptured abdominal aortic aneurysm; 46% of these cases were surgically treated whereas 54% received conservative therapy. The age-standardised cumulative hospital incidences for treatment of nonruptured abdominal aortic aneurysms were 2.6 (95% confidence interval 2.5-2.8) and 19.7 (19.2-20.1) per 100,000 for women and men, respectively; for ruptured aneurysms it was 0.4 (0.3-2.4) per 100,000 in women, and 2.7 (2.6-2.9) in men. The annual incidence rates were stable in the decade observed. The adjusted mortality rates for treatment of nonruptured aneurysms decreased from 5.5% (2.6-11.2%) in 2009 to 1.4% (0.5-3.6%) in 2018 in women, and from 2.4% (1.3-4.5%) in 2009 to 0.6% (0.2-1.5%) in 2018 in men. The adjusted mortality rates for treatment of ruptured abdominal aortic aneurysms remained high without relevant improvements for either sex over time: for women 32.4% (24.1-42.1%), for men 19.7% (16.8-22.8%). CONCLUSIONS The hospital incidence rates for nonruptured and ruptured abdominal aortic aneurysms remained unchanged in the decade observed. Compared with Germany, there was no evidence for a decrease in the annual incidence rates for ruptured abdominal aortic aneurysms in Switzerland. Mortality rates in the elective setting were low and decreased in the last decade but remained high in patients treated for ruptured aneurysms. Efforts to reduce the incidence of ruptured abdominal aortic aneurysms are needed to reduce aneurysm-related mortality in Switzerland

Relevance of Type II Endoleak After Endovascular Repair of Ruptured Abdominal Aortic Aneurysms: A Retrospective Single-Center Cohort Study

Introduction: Endovascular aortic repair (EVAR) is widely used as an alternative to open repair in elective and even in emergent cases of ruptured abdominal aortic aneurysm (rAAA). One of the most frequent complications after EVAR is type II endoleak (T2EL). In elective therapy, evidence-based therapeutic recommendations for T2EL are limited. Completely unclear is the role of T2EL after EVAR for rAAA (rEVAR). This study aims to investigate the significance of T2ELs after rEVAR. Patients and methods: This is a retrospective single-center data analysis of all patients who underwent rEVAR between January 2010 and December 2020 with primary T2EL. The outcome criteria were overall and T2EL-related mortality and reintervention rate as well as development of aneurysm diameter over follow-up (FU). Results: During the study period between January 2010 and December 2020, 35 (25%) out of 138 patients with rEVAR presented a primary postoperative T2EL (age 74±11 years, 34 males). At rupture, mean aneurysm diameter was 73±12 mm. Follow-up was 26 (0–172) months. The reintervention-free survival was 69% (95% confidence interval [CI]: 55%–86%) at 30 days, 58% (95% CI: 43%–78%) at 1 year, and 52% (95% CI: 36%–75%) at 3 years. In 40% (n=14), T2ELs resolved spontaneously within a median time of 3.4 (0.03–85.6) months. The overall and T2EL reintervention rates were 43% (n=15) and 9% (n=3), respectively. Within 30 days, 11 patients (31%) required reintervention, of which 2 were T2EL related. Aneurysm sac growth by ≥5 mm was seen in 3 patients (9%), and aneurysm shrinkage rate was significantly higher in sealed T2EL group (86% vs 5%, p<0.0001). The overall survival was 85% (95% CI: 74%–98%) at 30 days, 75% (95% CI: 61%–92%) at 1 year, and 67% (95% CI: 51%–87%) at 3 years. Six deaths were aneurysm related, while 1 was T2EL related within the first 30 days due to persistent hemorrhage. During FU, one more patient died due to a T2EL-related secondary rupture (T2EL-related mortality, 5.7%, n=2). Multivariable analysis revealed that arterial hypertension was associated with an increased risk for reintervention (hazard ratio [HR]: 27.8, 95% CI: 1.48–521, p=0.026) and age was associated with an increased risk for mortality (HR 1.14, 95% CI: 1.04–1.26, p=0.005). Conclusion: T2ELs after rEVAR showed a benign course in most cases. In the short term, the possibility of persistent bleeding should be considered. In the mid term, a consequent FU protocol is required to detect known late complications after EVAR at an early stage and to prevent secondary rupture and death

Helicopter inter-hospital transfer for patients undergoing extracorporeal membrane oxygenation: a retrospective 12-year analysis of a service system.

BACKGROUND Patients undergoing extracorporeal membrane oxygenation (ECMO) are critically ill and show high mortality. Inter-hospital transfer of these patients has to be safe, with high survival rates during transport without potentially serious and life-threatening adverse events. The Swiss Air-Rescue provides 24-h/7-days per week inter-hospital helicopter transfers that include on-site ECMO cannulation if needed. This retrospective observational study describes adverse events of patients on ECMO transported by helicopter, and their associated survival. METHODS All patients on ECMO with inter-hospital transfer by helicopter from start of service in February 2009 until May 2021 were included. Patients not transported by helicopter or with missing medical records were excluded. Patient demographics (age, sex) and medical history (type of and reason for ECMO), mission details (flight distance, times, primary or secondary transport), adverse events during the inter-hospital transfer, and survival of transferred patients were recorded. The primary endpoint was patient survival during transfer. Secondary endpoints were adverse events during transfer and 28-day survival. RESULTS We screened 214 ECMO-related missions and included 191 in this analysis. Median age was 54.6 [IQR 46.1-62.0] years, 70.7% were male, and most patients had veno-arterial ECMO (56.5%). The main reasons for ECMO were pulmonary (46.1%) or cardiac (44.0%) failure. Most were daytime (69.8%) and primary missions (n = 100), median total mission time was 182.0 [143.0-254.0] min, and median transfer distance was 52.7 [33.2-71.1] km. All patients survived the transfer. Forty-four adverse events were recorded during 37 missions (19.4%), where 31 (70.5%) were medical and none resulted in patient harm. Adverse events occurred more frequently during night-time missions (59.9%, p = 0.047). Data for 28-day survival were available for 157 patients, of which 86 (54.8%) were alive. CONCLUSION All patients under ECMO survived the helicopter transport. Adverse events were observed for about 20% of the flight missions, with a tendency during the night-time flights, none harmed the patients. Inter-hospital transfer for patients undergoing ECMO provided by 24-h/7-d per week helicopter emergency medical service teams can be considered as feasible and safe. The majority of the patients (54.8%) were still alive after 28 days

Swiss Vascular Biobank: Evaluation of Optimal Extraction Method and Admission Solution for Preserving RNA from Human Vascular Tissue

Proper biobanking is essential for obtaining reliable data, particularly for next-generation sequencing approaches. Diseased vascular tissues, having extended atherosclerotic pathologies, represent a particular challenge due to low RNA quality. In order to address this issue, we isolated RNA from vascular samples collected in our Swiss Vascular Biobank (SVB); these included abdominal aortic aneurysm (AAA), peripheral arterial disease (PAD), healthy aorta (HA), and muscle samples. We used different methods, investigated various admission solutions, determined RNA integrity numbers (RINs), and performed expression analyses of housekeeping genes (ACTB, GAPDH), ribosomal genes (18S, 28S), and long non-coding RNAs (MALAT1, H19). Our results show that RINs from diseased vascular tissue are low (2-4). If the isolation of primary cells is intended, as in our SVB, a cryoprotective solution is a better option for tissue preservation than RNAlater. Because RNA degradation proceeds randomly, controls with similar RINs are recommended. Otherwise, the data might convey differences in RNA degradation rather than the expressions of the corresponding genes. Moreover, since the 18S and 28S genes in the diseased vascular samples were degraded and corresponded with the low RINs, we believe that DV200, which represents the total RNA's disintegration state, is a better decision-making aid in choosing samples for omics analyses