[Show abstract][Hide abstract] ABSTRACT: Conventional management of abdominal aortic aneurysm (AAA) is by open repair and is associated with a mortality rate of 2-6 per cent. Endovascular aneurysm repair (EVAR) is an alternative technique first introduced in 1991. A systematic review was undertaken of the evidence for the safety and efficacy of elective EVAR in the management of asymptomatic infrarenal AAA.
Thirteen electronic bibliographical databases were searched, covering biomedical, health-related, science and social science literature. Outcomes were assessed with respect to efficacy (successful deployment, technical success, conversion rates and secondary intervention rates) and safety (30-day mortality rate, procedure morbidity rates and technical issues-endoleaks, graft thrombosis, stenosis and migration).
Of 606 reports identified, 61 met the inclusion criteria (three randomized and 15 non-randomized controlled trials, and 43 uncontrolled studies). There were 29 059 participants in total; 19,804 underwent EVAR. Deployment was successful in 97.6 per cent of cases. Technical success (complete aneurysm exclusion) was 81.9 per cent at discharge and 88.8 per cent at 30 days. Secondary intervention to treat endoleak or maintain graft patency was required in 16.2 per cent of patients. Mean stay in the intensive care unit and mean hospital stay were significantly shorter following EVAR. The 30-day mortality rate for EVAR was 1.6 per cent (randomized controlled trials) and 2.0 per cent in nonrandomized trials and case series. Technical complications comprised stent migration (4.0 per cent), graft limb thrombosis (3.9 per cent), endoleak (type I, 6.8 per cent; type II, 10.3 per cent; type III, 4.2 per cent) and access artery injury (4.8 per cent).
EVAR is technically effective and safe, with lower short-term morbidity and mortality rates than open surgery. However, there is a need for extended follow-up as the long-term success of EVAR in preventing aneurysm-related deaths is not yet known.
British Journal of Surgery 08/2005; 92(8):937-946. DOI:10.1002/bjs.5123 · 5.21 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To report meta-analyses of published clinical experiences with abdominal aortic dissection (AAD), a rare event that is accountable for up to 4% of all aortic dissections.
All English-language articles regarding abdominal aortic dissection were identified using MEDLINE, Cochrane Library Central, and EMBASE databases. All identified articles were critically appraised for relevance and validity before data extraction and the meta-analyses were performed. Original data were identified on 92 AAD patients (62 men; mean age 59+/-16 years).
Of all AADs, 73 (79%) were spontaneous, 13 (14%) traumatic, and 6 (7%) iatrogenic; the majority (68, 74%) were acute presentations. The mean dissection length was 59+/-16 mm. A pre-existing abdominal aortic aneurysm was present in 39 (42%). Hypertension was more frequently present in patients with spontaneous dissections compared to other dissection types (p = 0.001). Concurrent aortic aneurysms were more often associated with spontaneous dissections (p = 0.002). Aortic rupture occurred in 9 (10%) AADs. Open surgical repair was performed in 46 (50%), endovascular repair in 19 (21%), and conservative medical treatment in 27 (29%). In-hospital mortality was 4% overall [1 (2%) in the open repair group, 0 endovascular, and 2 (8%) conservative treatment]. Major complications occurred in 9% [6 (13%) in the open repair group, 1 (5%) in the endovascular group, and 1 (4%) in the conservative treatment cohort].
AAD is a rare event that appears to be associated with hypertension and pre-existing aneurysmal degeneration of the abdominal aorta. AAD patients are at considerable risk of in-hospital mortality and complications. Endovascular therapy appears to be associated with a relatively low risk of mortality or major complications compared to open repair and conservative treatment.
[Show abstract][Hide abstract] ABSTRACT: This study describes the design of an ongoing randomized trial initiated to compare the 2-year outcome of uncomplicated type B aortic dissection when treated by endovascular implantation of a Medtronic Talent stent graft adjunctive to best medical treatment versus best medical treatment alone.
Patients older than 18 years with type B aortic dissection as diagnosed by computed tomography or magnetic resonance angiography are randomized to either a thoracic aortic endoprosthesis and antihypertensive treatment, called "stent grafting," or a tailored antihypertensive treatment, called "medical treatment." Only patients in a clinically stable condition and without spontaneous thrombosis of the false lumen after 14 days of the index dissection are considered eligible for study inclusion.
Primary outcome measure is all-cause mortality. Secondary outcome variables include conversion to stent and/or surgery, induced thrombosis of the false lumen, cardiovascular morbidity, aortic expansion (>5 mm/y of maximum diameter including true and false lumina), quality of life, and length of intensive care unit and hospital stay. The study design calls for 136 patients to be randomized and monitored for 24 months.
The INSTEAD trial is the first randomized trial investigating the role of endoluminal treatment of uncomplicated type B aortic dissection. By the end of December 2004, 125 patients were randomized, accounting for 92% of the target. Final results of the INSTEAD trial should be available in 2006.
American heart journal 04/2005; 149(4):592-9. DOI:10.1016/j.ahj.2004.05.060 · 4.56 Impact Factor
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