Low Socioeconomic Status is an Independent Risk Factor for Survival After Abdominal Aortic Aneurysm Repair and Open Surgery for Peripheral Artery Disease

OBJECTIVE/BACKGROUND: The association between socioeconomic status (SES), presentation, and outcome after vascular surgery is largely unknown. This study aimed to determine the influence of SES on post-operative survival and severity of disease at presentation among vascular surgery patients in the Dutch setting of equal access to and provision of care. METHODS: Patients undergoing surgical treatment for peripheral artery disease (PAD), abdominal aortic aneurysm (AAA), or carotid artery stenosis between January 2003 and December 2011 were retrospectively included. The association between SES, quantified by household income, disease severity at presentation, and survival was studied using logistic and Cox regression analysis adjusted for demographics, and medical and behavioral risk factors. RESULTS: A total of 1,178 patients were included. Low income was associated with worse post-operative survival in the PAD cohort (n = 324, hazard ratio 1.05, 95% confidence interval [CI] 1.00-1.10, per 5,000 Euro decrease) and the AAA cohort (n = 440, quadratic relation, p = .01). AAA patients in the lowest income quartile were more likely to present with a ruptured aneurysm (odds ratio [OR] 2.12, 95% CI 1.08-4.17). Lowest income quartile PAD patients presented more frequently with symptoms of critical limb ischemia, although no significant association could be established (OR 2.02, 95% CI 0.96-4.26). CONCLUSIONS: The increased health hazards observed in this study are caused by patient related factors rather than differences in medical care, considering the equality of care provided by the study setting. Although the exact mechanism driving the association between SES and worse outcome remains elusive, consideration of SES as a risk factor in pre-operative decision making and focus on treatment of known SES related behavioral and psychosocial risk factors may improve the outcome of patients with vascular disease

Decision-making in follow-up after endovascular aneurysm repair based on diameter and volume measurements:a blinded comparison

AbstractObjective: to assess whether volume, in addition to diameter, measurements facilitate decision-making after endovascular aneurysm repair (EVAR). Material/Methods: patients (n = 82) with an immediately post-EVAR, and at least one follow-up (3-60 months), computed tomographic angiogram (CTA) were studied. The actual and all preceding proportional sac size changes were recorded. The resulting 347 diameter and 347 volume data were placed in random order and reviewed by three blinded observers who then recommended one of three treatment policies: “good/wait”, “uncertain/intensify follow-up” or “not good/further diagnostics (Dx) or intervention (Rx)”. The observers were instructed to consider changes of 10% relevant. One observer reviewed the graphs twice. Results: the interobserver agreements (kappa) for the diameter were 0.92, 0.81 and 0.76 and for volumes 0.91, 0.88 and 0.86. The intra-observer agreement was 0.93 for both diameter and volume. Volume data resulted in significantly more “good/wait” decisions out to 36 months. Diameter data resulted in more “not good/Dx or Rx”-decisions out to 36 months (all p < 50.005). Conclusion: post-EVAR aneurysm sac volume data appears to provide earlier reassurance, reduce unnecessary interventions and to be more sensitive to secondary problems than diameter data alone.Eur J Vasc Endovasc Surg 26, 184-187 (2003

Endovascular repair for aorto-enteric fistula: A bridge too far or a bridge to surgery?

AbstractPurposeTo review our experience of endovascular treatment of aorto-enteric fistula (AEF).MethodsBetween March 1999 and March 2005, 15 patients in five university and teaching hospitals in Belgium and The Netherlands were treated for AEF by endovascular repair. Twelve (80%) were male. The mean age was 67 years. Thirteen (87%) had had previous aortic or iliac surgery, 1.7–307 months before. All patients showed clinical or biochemical signs of bleeding. Eight (53%) were in shock, five (33%) had systemic signs of infection.Eight (53%) patients were treated in an emergency setting. Ten (67%) were treated with an aortouniiliac device, three (20%) with an aortobiiliac device, one with a tube graft and one with occluders only. All patients received antibiotics postoperatively for a prolonged period of time.ResultsAll AEF were successfully sealed, the 30-days mortality was nil. Mean hospital stay was 20 (2–81) days. One patient died 2.7 months later of postoperative complications, one died of lung cancer. Until now, there are no signs of reinfection in four (27%) patients (mean follow-up 15.7 (1–44) months). However, reinfection or recurrent AEF occurred in nine (60%) patients after 9.5 (0.61–31) months. Seven patients were reoperated successfully, two patients died after reintervention.ConclusionEndovascular sealing of AEF is a promising technique, which provides time to treat shock, local and systemic infection, and co-morbidity. This creates a better situation to perform open repair in the future with possibly better outcome. Danger of reinfection remains high. Endovascular sealing of AEF should, therefore, be seen as a bridge to open surgery when possible

Sirolimus-eluting stents to abolish intimal hyperplasia and improve flow in porcine arteriovenous grafts - A 4-week follow-up study

Background - The patency of arteriovenous ( AV) expanded polytetrafluoroethylene (ePTFE) hemodialysis grafts is severely compromised by intimal hyperplasia (IH) at the venous anastomosis and in the venous outflow tract. We addressed the potential of primary placement of a sirolimus-eluting stent (SES) in a validated porcine model. Methods and Results - In 25 pigs, ePTFE AV grafts were created bilaterally between the carotid artery and the jugular vein, whereupon a self-expandable nitinol stent ( 14 SESs and 11 bare-metal stents) was implanted over the venous anastomosis in 1 of the 2 grafts. After exclusion of technical failures and 1 unilateral occlusion, 16 pigs ( 9 SESs and 7 bare-metal stents) were included for further analysis. After 28 days, we measured graft flow and performed quantitative angiography. The pigs were then euthanized, and grafts with adjacent vessels were excised for histological analysis. Minimal luminal diameter was substantially larger in the SES group compared with unstented controls ( 5.9 +/- 0.2 versus 3.8 +/- 0.4 mm, respectively, P = 0.01), which was accompanied by more prominent graft flow ( SES, 1360 +/- 89 mL/min versus unstented, 861 +/- 83 mL/min, P = 0.05). IH at the venous anastomosis was 77% less in the SES group compared with unstented controls (0.44 +/- 0.05 versus 1.92 +/- 0.5 mm(2), respectively, P = 0.01), whereas IH increased markedly when bare-metal stents were used (5.7 +/- 1.4 mm(2), P = 0.05). Conclusions - SESs in the venous outflow of AV grafts significantly reduce IH and increase vessel diameter and graft flow compared with unstented grafts. These findings suggest that SESs have the potential to improve primary patency of AV grafts in hemodialysis patients