Outcomes in Patients Turned Down for Aortic Surgery: An Important Indicator of Responsible Patient Selection

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FFR improved significantly after angioplasty/stenting [0.91 (0.80-
1.00), P<0.0001].
Conclusions: FFR may better indicate the functional significance of
lower limb lesions than current tools. Clinical trials will determine
whether FFR will become, as it has in the coronary circulation, the
gold standard for making treatment decisions.
Aortic Prize Abstracts
Anaesthesia Technique and Outcomes Following Endovascular
Aneurysm Repair of Ruptured Abdominal Aortic Aneurysm
Ronelle Mouton
1
, George Dovell
2,3
, Chris Rogers
4
, Rosie Harris
4
,
Robert Hinchliffe
2,3
1
Department of Anaesthesia, Southmead Hospital, Bristol, UK
2
Bristol, Bath and Weston Vascular Network, Bristol, UK
3
NIHR Bristol BRC, University of Bristol, Bristol, UK
4
Bristol Surgical Trials Centre, Bristol, UK
Background: The post-hoc subgroup analysis of a large randomized
controlled trial, alongside a single case series, has suggested a po-
tential benefit from managing ruptured abdominal aortic aneurysms
(rAAA) with endovascular repair (EVAR) using local anaesthesia (LA)
rather than general anaesthesia (GA). The uptake and outcomes of
this technique in everyday clinical practice are as yet unknown.
Methods: A retrospective analysis of the United Kingdom (UK)
National Vascular Registry (NVR) was conducted between 1st
January 2013 and 31st December 2016. All patients presenting
with rAAA that were managed with EVAR were included in the
analysis. The primary outcome was in-hospital mortality. Second-
ary outcomes included the number of centres offering LA EVAR,
the length of stay and postoperative complications.
Results: Some 3101 patients with rAAA were managed in 72
hospitals; 2306 open procedures and 795 EVAR (319 LA, 435 GA
and 41 regional anaesthesia). Overall, 56/72 hospitals (78%)
offered LA EVAR for rAAA. Baseline characteristics and morphology
were similar across the three EVAR sub-groups. Patients who had
LA EVAR, had a lower in-hospital mortality compared to GA EVAR,
59/319 (18.5%) versus 22/435 (28.0%) and this was unchanged
after adjustment for factors known to influence survival (adjusted
hazard ratio 0.64, 95%CI 0.46 to 0.88, p¼0.006).
Conclusion: The use of local anaesthesia for the endovascular
management of rAAA has been widely adopted in the UK. Mor-
tality rates appear lower in those undergoing local versus general
anaesthesia.
Outcomes in Patients Turned Down for Aortic Surgery: An
Important Indicator of Responsible Patient Selection
Amy Sharkey, Ashish Patel, Jun Cho, Jayna Patel, Tommaso Donati,
Becky Sandford, Sanjay Patel, Lukla Biasi, Said Abisi, Stephen Black,
Michael Dialynas, Morad Sallam, Hany Zayed, Rachel Bell,
Mark Tyrrell, Bijan Modarai
Academic Department of Vascular Surgery, School of Cardiovascular Medicine
and Sciences, King’s College London, BHF Centre of Research Excellence & NIHR
Biomedical Research Centre at King’s Health Partners, St Thomas’Hospital,
London, UK
Background: Studies reporting the fate of patients deemed un-
suitable for aortic aneurysm repair (‘turndowns’) are sparse. Our
aim was to compare outcomes between turndowns and those
managed operatively.
Methods: Data were collected on all patients referred to a tertiary
referral centre with an aortic aneurysm over an 18-month period
beginning April 2016. Kaplan-Meier analysis was used to measure
survival and multivariate analysis to determine factors that pre-
dicted turned down.
Results: 568 patients were considered for intervention; complete
data were available for 531(infra- renal:284, juxta-renal:106,
thoracic:41, thoraco-abdominal:100). Mean age was 76.4yrs, and
80.0% were male. 345 patients (73 emergent) were managed
operatively (endovascular:272, open:73). 86 [16.2%] patients were
turned-down (infra-renal:40, juxta- renal:18, thoracic:5, thoraco-
abdominal:23). Median follow-up was 156 (38e343) days. Renal
disease, cardiac disease and history of TIA/stroke predicted turn-
down (P<0.05 for all). One- year all-cause mortality for elective
open and endovascular procedures was 2.4% and 5.2%, respec-
tively (infra-renal EVAR:0.4%, TEVAR:0.9%, complex endovascular
repair:3.9%). One- year aneurysm related and all-cause mortality
for those turned down for elective surgery was 7.1% and 21.4%,
respectively, with a third of these patients dying from cancer
rather than aneurysm rupture.
Conclusions: The short term aneurysm-related mortality in elective
turndowns is low, with a significant number of patients suc-
cumbing for other reasons. Given the plethora of treatment op-
tions available, objective selection of patients who will benefit
most from intervention is increasingly important.
The Impact of Endovascular Aneurysm Repair on Long-term
Renal Function
Edmund R. Charles
1
, Dennis Lui
1
, Jonathan Delf
1
,
Robert D. Sayers
2
, Matthew J. Bown
2
, David Sidloff
2
,
Athanasios Saratzis
2
1
Leicester Vascular Institute, Leicester, UK
2
NIHR Leicester Biomedical Research Centre, Leicester, UK
Background: Endovascular Aneurysm Repair(EVAR) is associatedwith
superior short-term outcomes compared with open repair; however,
concerns have been raised over the impact of EVAR on renal function.
Long-term renal outcomes after EVAR remain largely unknown. We
therefore aimed to define long-term renal decline following elective
EVAR, using estimated Glomerular Filtration Rate (eGFR).
Methods: We used our in-house database of elective EVAR to
identify consecutive patients who had been followed-up for more
than 5 years. Subsequently, 270 consecutive patients (24 females
e8.6%, mean age: 71 years) who were not previously on Renal
Replacement Therapy (RRT) were included; they had undergone
elective EVAR between January 2000 and July 2010. We examined
pre-operative, post-operative, and most recent eGFR values using
the CKD-EPI equation. The primary outcome was change in eGFR at
latest follow-up.
Results: Patients were followed-up over a median of 9 years
(range: 5-17 years). Their mean eGFR dropped from a pre-opera-
tive value of 67 ml/min/1.732 [Standard Deviation (SD): 9.4] to 52
ml/min/1.732 (SD: 7.7), which amounts to a yearly loss of 1.7
units. Overall, 6 patients (2%) required RRT during late follow-up.
Patients requiring RRT and those with an eGFR loss exceeding 20%
at latest follow-up were more likely to die (Odds Ratio: 2.4 and 3.3
respectively, p<0.001).
Conclusion: This analysis, with the longest available follow-up to
date, suggests that patients undergoing EVAR have a drop in renal
function almost 3 times higher of the expected annual renal
decline and that may be associated with mortality.
Abstracts e29