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

Decreased plasma nociceptin/orphanin FQ levels after acute coronary syndromes

Foregoing researches made on the N/OFQ system brought up a possible role for this system in cardiovascular regulation. In this study we examined how N/OFQ levels of the blood plasma changed in acute cardiovascular diseases. Three cardiac patient groups were created: enzyme positive acute coronary syndrome (EPACS, n = 10), enzyme negative ACS (ENACS, n = 7) and ischemic heart disease (IHD, n = 11). We compared the patients to healthy control subjects (n = 31). We found significantly lower N/OFQ levels in the EPACS [6.86 (6.21–7.38) pg/ml], ENACS [6.97 (6.87–7.01) pg/ml and IHD groups [7.58 (7.23–8.20) pg/ml] compared to the control group [8.86 (7.27–9.83) pg/ml]. A significant correlation was detected between N/OFQ and white blood cell count (WBC), platelet count (PLT), creatine kinase (CK), glutamate oxaloacetate transaminase (GOT) and cholesterol levels in the EPACS group.Decreased plasma N/OFQ is closely associated with the presence of acute cardiovascular disease, and the severity of symptoms has a significant negative correlation with the N/OFQ levels. We believe that the rate of N/OFQ depression is in association with the level of ischemic stress and the following inflammatory response. Further investigations are needed to clarify the relevance and elucidate the exact effects of the ischemic stress on the N/OFQ system

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

Second asymptomatic carotid surgery trial (ACST-2): a randomised comparison of carotid artery stenting versus carotid endarterectomy

Background: Among asymptomatic patients with severe carotid artery stenosis but no recent stroke or transient cerebral ischaemia, either carotid artery stenting (CAS) or carotid endarterectomy (CEA) can restore patency and reduce long-term stroke risks. However, from recent national registry data, each option causes about 1% procedural risk of disabling stroke or death. Comparison of their long-term protective effects requires large-scale randomised evidence. Methods: ACST-2 is an international multicentre randomised trial of CAS versus CEA among asymptomatic patients with severe stenosis thought to require intervention, interpreted with all other relevant trials. Patients were eligible if they had severe unilateral or bilateral carotid artery stenosis and both doctor and patient agreed that a carotid procedure should be undertaken, but they were substantially uncertain which one to choose. Patients were randomly allocated to CAS or CEA and followed up at 1 month and then annually, for a mean 5 years. Procedural events were those within 30 days of the intervention. Intention-to-treat analyses are provided. Analyses including procedural hazards use tabular methods. Analyses and meta-analyses of non-procedural strokes use Kaplan-Meier and log-rank methods. The trial is registered with the ISRCTN registry, ISRCTN21144362. Findings: Between Jan 15, 2008, and Dec 31, 2020, 3625 patients in 130 centres were randomly allocated, 1811 to CAS and 1814 to CEA, with good compliance, good medical therapy and a mean 5 years of follow-up. Overall, 1% had disabling stroke or death procedurally (15 allocated to CAS and 18 to CEA) and 2% had non-disabling procedural stroke (48 allocated to CAS and 29 to CEA). Kaplan-Meier estimates of 5-year non-procedural stroke were 2·5% in each group for fatal or disabling stroke, and 5·3% with CAS versus 4·5% with CEA for any stroke (rate ratio [RR] 1·16, 95% CI 0·86–1·57; p=0·33). Combining RRs for any non-procedural stroke in all CAS versus CEA trials, the RR was similar in symptomatic and asymptomatic patients (overall RR 1·11, 95% CI 0·91–1·32; p=0·21). Interpretation: Serious complications are similarly uncommon after competent CAS and CEA, and the long-term effects of these two carotid artery procedures on fatal or disabling stroke are comparable. Funding: UK Medical Research Council and Health Technology Assessment Programme

Ezüst-acetáttal bevont Dacron grafttal végzett rekonstrukciós érmutétek középtávú eredményei

Prosthetic graft infection or the need for reconstructive arterial surgery in septic condition is a challenging situation in vascular surgery. Recent introduction of silver coated polyester graft has meant a new therapeutic option in selecting the type of graft for revascularization. In this study we analyzed the short and midterm outcome of using silver coated grafts in aortic and lower extremity arterial reconstructions (mortality, graft occlusion, graft infection, amputation). In a single center retrospective study we implanted 42 silver coated Dacron grafts (InterGard Silver Dacron prosthesis). The indication of silver graft implantation was graft infection in 17, aorto-duodenal fistula in 7, septic condition caused by gangrene in 16 cases and in 2 cases infection was not established. Forty silver grafts were implanted in 40 patients with diagnosed infection. The mean age was 62 years (35-81 years), 70% were men. Long term follow-up data were available in 29 patients; the mean follow-up time was 36.76 months. Early (within 30 days of surgery) death occurred in 3 and late death in 11 cases (8 and 38%). Early graft occlusion was noticed in 8 and late occlusion in 2 cases (20 and 7%). Reinfection was diagnosed in 7% of the cases in the early and the midterm period as well. Eight amputations were indicated in the early postoperative period (5 major and 3 minor) and 28% of the patients required major amputation during the follow-up. Silver coated Dacron graft means a valuable therapeutic option with good rate of infection control in the treatment of graft infection and septic condition in the lack of autologous graft material in this high risk population

A comparison of clinical outcomes of abdominal aortic aneurysm patients with favorable and hostile neck angulation treated by endovascular repair with the Treovance stent graft

Objective: The objective of this study was to compare outcomes of patients with favorable neck angulation (FNA) and hostile neck angulation (HNA) treated with the Treovance stent graft (Terumo Aortic [formerly Bolton Medical], Sunrise, Fla). Methods: Patients with abdominal aortic aneurysms suitable for endovascular repair with Treovance were included in the RATIONALE postmarket surveillance registry. A post hoc subgroup analysis compared patients with infrarenal neck angles &lt;60 degrees (FNA) and ≥60 degrees (HNA). Results: After 1 year, 179 FNA (89.5%) and 21 HNA (10.5%) patients were analyzed. Both groups were similar in terms of sex (male, 92.7% FNA and 95.2% HNA) and age (73.0 years vs 72.6 years), but the HNA group had more Asian or other race representation (7.3% vs 19.0%) and more patients assigned to American Society of Anesthesiologists class 3 and class 4 (57.6% vs 66.7%). Mean suprarenal angles (standard deviation) were 13.1 (±13.5) degrees vs 29.0 (±16.4) degrees; mean infrarenal angles were 23.2 (±16.4) degrees vs 65.4 (±4.6) degrees, respectively. Aneurysm sac size maximum diameter was 58.1 (±9.8) mm vs 62.0 (±14.1) mm. There was a significant difference in unplanned adjunctive procedures (2.2% vs 19.0%; P =.01). Mean procedural duration was also significantly different for HNA patients, who underwent protracted operations (111.3 [±47.3] minutes vs 153.5 [±44.5] minutes; P &lt;.0001). However, there were no significant differences in rates of clinical success (96.1% vs 95.2%). The rate of reintervention was low overall but 0% in the HNA group. Changes in sac size at 1 year were significant in both groups but not as pronounced in HNA patients (relative change of −11.8% [±13.3] vs −6.6% [±11.4]). Conclusions: Patients with high neck angulation treated with Treovance underwent more complex procedures but showed equally good technical success and 1-year clinical success parameters

Mellkasiaortastentgraft-beültetések Magyarországon 2012 és 2016 között [Thoracic aortic stentgraft implantations in Hungary from 2012 to 2016]

Thoracic aortic endograft implantation has become a widespread procedure in recent years, yet no report is available about Hungarian outcomes. Examination of our results is crucial to define further treatment strategies. Analysis of perioperative data from Hungarian thoracic endograft implantations based on the experience of 5 years is presented. Our retrospective, multicentric study analysed voluntarily reported data from all Hungarian institutions where thoracic endograft implantations are performed. Information was collected from every procedure performed in 5 years. Between 2012 and 2016, 131 thoracic stent graft implantations were performed in Hungary (67.18% male, mean age 62.80 years). 25.19% of the procedures were acute. 13.74% of the patients were diabetic. Indications for the procedure were aneurysm (64.89%), dissection (17.56%), aortic trauma (6.87%) and other conditions (10.69%). 73.91% of the dissection cases were acute. 16.47% of repaired aneurysms were ruptured. Additional preoperative revascularization (debranching) was performed in 26.72% of the cases. Postoperative stroke occured in 4.58%, temporary hemodialysis was needed in 1.53%, bowel ischaemia was present in 2.29% and reoperation within 30 days was needed in 5.34% of all cases. Thirty-day mortality of the procedure was 9.92%, 5-year long-term mortality reached 16.03%. Endovascular repair of the thoracic aorta is an effective procedure and our national data comfirmed its advantages compared to open thoracic surgery. Further use of the procedure in Hungary depends on the centralised care in vascular surgery and financial matters. Multidisciplinary cooperation and proper logistics are needed to provide patients with optimal treatment. Orv Hetil. 2018; 159(2): 53-57