Presence of atherosclerosis in multiple arterial beds is associated with increased mortality in patients undergoing endovascular aortic aneurysm repair

Selected in ESVS Journal by Perrine Darpy

This retrospective study aimed to quantify the impact of atherosclerotic disease burden on mortality and morbidity in patients undergoing elective endovascular aneurysm repair (EVAR) for aneurysmal disease. The research focused on patients who underwent EVAR between 2012 and 2022, assessing the presence of atherosclerosis in multiple arterial beds and its association with peri-operative outcomes, specifically death and major adverse cardiovascular events (MACE).

References:

Authors: Molly Ratner, Heepeel Chang, Caron B. Rockman, Benjamin J. Pearce, Jeffrey J. Siracuse, Jae S. Cho, Neal Cayne, Thomas Maldonado, Virendra Patel, Karan Garg

Reference: Eur J Vasc Endovasc Surg Volume 69, Issue 1, p81-87, January 2025

DOI: DOI: 10.1016/j.ejvs.2024.10.004

Read the abstract

Objective:

To quantify the effects of atherosclerotic disease burden on mortality and morbidity in patients undergoing elective endovascular aneurysm repair (EVAR) for aneurysmal disease.

Study:

This retrospective study used the Vascular Quality Initiative (VQI) database from the Society for Vascular Surgery (SVS).

Population:

Patients who underwent EVAR between 2012 and 2022.

Endpoints:

Death and MACE.

Presence of atherosclerosis in multiple arterial beds is associated with increased mortality in patients undergoing endovascular aortic aneurysm repair - Table

Source: ESVS Journal

Outcomes and conclusion:

In patients undergoing EVAR, those with polyvascular disease more frequently experienced peri-operative MACE and death. Moreover, a gradation of risk was observed with the increasing number of arterial beds involved. Patients with polyvascular disease should be considered high risk and managed accordingly.

Comments:

This study underscores the higher risk of peri-operative complications, including MACE and mortality, in patients with polyvascular disease undergoing EVAR. These patients should be considered high risk and managed accordingly.
Preoperative optimisation is crucial, with a focus on improving physical condition and potentially opting for local anesthesia over general anesthesia, as recommended by the ESVS 2024 guidelines.
The findings are consistent with other studies:
- Adkar et al. found that comorbid cardiac diseases increase the risk of death by a factor of 1.55 within 30 days post-surgery.
- Giles et al. proposed a risk scoring system to predict mortality after aneurysm repair, considering factors like age, renal insufficiency, heart failure, and vascular disease.
- Malas et al. observed higher peri-operative mortality with EVAR compared to open repair (1.3 % vs 0.2 %), suggesting that EVAR may not offer the same benefits for very high-risk patients, as the advantages of minimally invasive techniques diminish for such cases.
- Additionally, peri-operative mortality at 30 days in this study was found to be 2.8 %, a higher rate compared to other clinical trials, highlighting the importance of identifying and addressing high-risk patients.

Study limitations:

Retrospective design: the study relies on historical data, which could introduce selection biases and limit the generalizability of the findings.
All-cause mortality data: the registry-based data includes all-cause mortality, rather than specifically vascular-related deaths, which could affect the accuracy of the conclusions.
Inclusion of symptomatic patients: the study included patients who had already undergone previous interventions, which may increase their baseline risk and could influence the outcomes.
Lack of detailed aneurysm anatomy: there was no information on the specific anatomy of the aneurysms (e.g., neck, length, diameter, angulation), which could have impacted both treatment planning and outcomes.
Unexplored variables: factors such as the choice of anesthesia (local vs. general) and preoperative optimization were not systematically analyzed in relation to outcomes, leaving room for further research.