Louise C. Brown

Background: It is uncertain which baseline factors are associated with graft-related complications and reinterventions after endovascular aneurysm repair (EVAR) in patients with a large abdominal aortic aneurysm. Methods: Patients randomized to elective EVAR in EVAR Trial 1 or 2 were followed for serious graft-related complications (type 2 endoleaks excluded) and reinterventions. Cox regression analysis was used to investigate whether any prespecified baseline factors were associated with time to first serious complication or reintervention. Results: A total of 756 patients who had elective EVAR were followed for a mean of 3·7 years, by which time there were 179 serious graft complications (rate 6·5 per 100 person years) and 114 reinterventions (rate 3·8 per 100 person years). The highest rate was during the first 6 months, with an apparent increase again after 2 years. Multivariable analysis indicated that graft-related complications increased significantly with larger initial aneurysm diameter (P < 0·001) and older age (P = 0·040). There was also evidence that patients with larger common iliac diameters experienced higher complication rates (P = 0·011). Conclusion: Graft-related complication and reintervention rates were common after EVAR in patients with a large aneurysm. Younger patients and those with aneurysms closer to the 5·5-cm threshold for intervention experienced lower rates.

To investigate the impact of different management policies on renal function in patients with abdominal aortic aneurysm. Limited longitudinal data exist on alterations in renal function in patients with abdominal aortic aneurysm. Escalating use of endovascular aneurysm repair (EVAR) with increased use of intensive imaging and contrast agents may have a deleterious effect on renal function. Multilevel modeling of estimated Glomerular Filtration Rate (eGFR), measured annually over an average of 3.6 years, was performed on 1194 patients enrolled in the randomized EVAR trials to compare renal function in patients managed with open or endovascular repair or no intervention and investigate, which factors were associated with fast renal decline. For EVAR trial 1, the mean (SD) rate of change in eGFR was −1.13 (1.43) and −1.00 (1.43) mL/min/1.73 m2 per year for the EVAR and open repair groups, respectively, but this difference was not statistically significant (P = 0.208). For EVAR trial 2, the mean (SD) rate of change in eGFR was −0.98 (1.49) and −0.76 (1.30) mL/min/1.73 m2 per year for the EVAR and no intervention groups, respectively (P = 0.087). Faster rates of renal function decline were significantly associated with larger aortic neck diameters (P = 0.003) and onset of graft-related complications after EVAR (P = 0.001). In these patients deterioration in renal function was slow, with little evidence to suggest any long-term difference between treatment with EVAR or open repair in fit patients or between EVAR and no intervention in unfit patients. Graft complications and larger neck diameters appear to be associated with faster renal function decline.

Background: The aim was to use a validated fitness score to determine whether fitter patients with a large abdominal aortic aneurysm (AAA) benefited from having open rather than endovascular repair. Methods: The Customized Probability Index (CPI) was applied to patients in the Endovascular Aneurysm Repair (EVAR) I and II trials. Interaction tests between CPI and randomized group assessed the effect of fitness and type of AAA repair on elective 30-day mortality and 4-year survival. Results: The mean(s.d.) CPI scores were 3·6(9·3) for 1252 EVAR I patients and 10·0(11·3) for 404 EVAR II patients (range − 25 to + 43) (P < 0·001). The fitness of EVAR I patients was classified as good (579 patients, mean CPI − 4·2), moderate (331 patients, mean CPI 5·7) or poor (338 patients, mean CPI 15·1). Only in the good fitness group did 30-day mortality convincingly favour endovascular repair (odds ratio 0·24, P = 0·030), but overall the test of interaction was not significant (P = 0·363). For 4-year all-cause and aneurysm-related mortality, there was no benefit for either treatment across all fitness scores (P = 0·281 and P = 0·371 respectively). Conclusion: The benefit of endovascular repair was most convincing in the fittest patients. There was no evidence that the fittest patients benefited more from open surgery.