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Thoracic endoscopic stent graft versus open surgery for thoracic aneurysm

An aneurysm is a localised dilation or widening of an artery. Thoracic aneurysm is a relatively infrequent disease that affects both older men and women. The cause of thoracic aneurysm is unknown but the aneurysms generally do not cause symptoms. They are, however, likely to increase in size. Patients who do not receive surgical treatment at the time of diagnosis have a greater chance of dying from rupture of the aneurysm. Aneurysms greater than 5 cm carry a higher risk of bursting. Surgical repair of aneurysms requires general anaesthesia and opening of the chest wall to place an artificial graft in the area of the diseased vessel. This is associated with procedure‐related deaths and complications such as paraplegia, stroke, and renal failure and excludes some patients because of age and accompanying illnesses. Endovascular repair is a recently introduced, minimally invasive technique in which a stent is delivered through a blood vessel and fixed to the aneurysm. A seal forms between the stent and the vessel wall so that blood does not flow between the two. We searched for evidence of the effectiveness of endovascular repair compared with open surgical repair for thoracic aneurysms. No randomised controlled trials were found in the medical literature. Reports from non‐randomised studies suggest that endovascular repair is technically feasible and may reduce early negative outcomes including death and paraplegia. However, stent devices have late complications that are uncommon to open surgery (for example, development of leaks, graft migration, need for re‐intervention) and patients receiving stents may require frequent surveillance with computed tomography (CT) scans.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2013

Screening for abdominal aortic aneurysm

An aneurysm is a localised widening (dilation) of an artery. The blood vessel can burst (rupture) because the vessel wall is weakened. Some 5% to 10% of men aged between 65 and 79 years have an abdominal aneurysm in the area of the aorta, the main artery from the heart as it passes through the abdomen. Abdominal aortic aneurysms are often asymptomatic but a rupture is a surgical emergency and often leads to death. An aneurysm larger than 5 cm carries a high risk of rupture. Smaller aneurysms are monitored regularly using ultrasound to see if they are becoming larger. Elective surgical repair of aortic aneurysms aims to prevent death from rupture. The incidence of aortic aneurysm in women as they age is lower than for men.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2011

Distal aortic perfusion during thoracoabdominal aneurysm repair for prevention of paraplegia

Aneurysm of an artery is a localised abnormal dilation with a diameter of the artery at least one and a half times its normal size. Aneurysms in both the thoracic and abdominal aorta are termed thoracoabdominal aortic aneurysms (TAAA). Open surgical repair is effective in ensuring the survival of people with such aneurysms. Complications of paralysis of the legs and lower parts of the body (paraplegia) and partial paralysis affecting the lower limbs (paraparesis) can however develop during surgery and in the postoperative period, following apparently successful surgery. This is the result of inadequate blood flow to the spinal cord and the vulnerability of the spinal cord to ischaemic injury.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2012

Medical treatment of vascular risk factors for reducing mortality and cardiovascular events in people with abdominal aortic aneurysm

Abdominal aortic aneurysm (AAA) is a potentially life‐threatening condition where the aorta enlarges and can ultimately burst leading to massive internal bleeding. Current guidelines recommend that AAAs ≥ 55 mm should be surgically repaired as at this size the risk of rupture outweighs the risk of surgical repair. AAAs between 30 and 54 mm in size are not as high risk and are generally monitored by regular scans to check for further enlargement. Recent research has shown that even after the aneurysm is repaired, the survival rate in people with AAA is poorer than in people without AAA. In the majority of cases, the cause of death is a cardiovascular event such as a heart attack or a stroke. Conditions such as high blood pressure or high cholesterol increase the risk of cardiovascular death. However, both conditions can be reversed through medical treatment. Given the increased risk of mortality with AAA, it is important to determine which medical treatment is most effective in preventing cardiovascular death in people with AAA.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2014

The use of anticoagulants to prevent deep venous thrombosis and pulmonary embolism following surgery for abdominal aortic aneurysm

Deep vein thrombosis (DVT) is a preventable complication of surgery. The blood clot can break away and travel to the lungs to cause respiratory distress and death (pulmonary embolism). Deep vein thrombosis is believed to occur less often following aortic surgery than in general surgical operations because heparin used during most vascular operations may protect against intra‐operative DVT. Vascular patients are usually older, with more co‐morbidity (presence of other diseases or conditions), and are subject to prolonged immobility, which increase the likelihood of developing DVT. Bleeding (haemorrhagic) complications could however occur if further anticoagulants are used for DVT prophylaxis during recovery.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2011

Endovascular treatment for ruptured abdominal aortic aneurysm

The abdominal aorta is the main artery supplying blood to the lower part of the body. An abnormal ballooning and weakening of the wall of the aorta (aortic aneurysm) particularly affects men as they grow older. An aneurysm may progressively enlarge without obvious symptoms yet it is potentially lethal as the aneurysm can burst (rupture) causing massive internal bleeding. Death is inevitable unless the bleeding can be stopped and blood flow to the lower body restored promptly. Until recently this required an open operation (laparotomy) to clamp the abdominal aorta and replace the segment of the aorta with a synthetic artery tube‐graft. Many patients do not survive this major operation due to the effects of massive bleeding or failure of vital organs, such as the heart, lungs, and kidneys, despite improvements in the surgical technique and care of the critically ill patient.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2014

Cerebrospinal fluid drainage for thoracic and thoracic abdominal aortic aneurysm surgery

An aneurysm is a local bulging of a blood vessel that carries a risk of rupture. Surgery for an aortic aneurysm requires clamping the aorta, the biggest artery in the body. This reduces the supply of blood and oxygen to the spinal cord (ischaemia) and tissue damage can lead to the partial or incomplete paralysis of the lower limbs (paresis) and paraplegia (paralysis of the legs and lower part of the body). These deficits are frequently irreversible. The cerebrospinal fluid (CSF) pressure increases during clamping further decreasing the perfusion pressure of the spinal cord. As more of the blood supply to the spinal cord is interrupted, the likelihood of paraplegia is increased. Various treatments are used to reduce the ischaemic insult to the spinal cord including temporary blood shunts (such as distal atriofemoral bypass and re‐connection of intercostal and lumbar vessels), pharmaceutical interventions (to protect the heart and cerebral blood vessels), epidural cooling and CSF drainage. Draining CSF from the lumbar region may lessen the CSF pressure, improve blood flow to the spinal cord and reduce the risk of ischaemic spinal cord injury.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2012

Endovascular repair of abdominal aortic aneurysm

The abdominal aorta is a major blood vessel in the body that carries blood from the heart to the major organs in the chest and abdomen. An abdominal aortic aneurysm (AAA) is a balloon‐like bulge (dilation) of the aorta that is greater than 3 cm in diameter. If an AAA ruptures (bursts), this is often fatal. Hence, AAAs that are larger than 5.5 cm are usually treated surgically in order to try to prevent such a rupture. Traditionally, AAAs are treated using an open surgical repair (OSR) technique, in which the abdomen is cut open (referred to as open surgery) and the dilated aorta is repaired using fabric graft material. However, over the past 20 years, a newer, 'key hole' technique has been used, in which the AAA is repaired without the need for open surgery ‐ a thin tube is passed via the blood vessels in the groin to the site of the AAA. Once in the correct position, a sheath is introduced that acts to reline the dilated aorta, acting as an artifical blood vessel through which blood can continue to flow, bypassing the aneurysm. Hence, the risk of further expansion or rupture of the AAA is reduced, This technique is referred to as endovascular aneurysm repair (EVAR). As EVAR is a less invasive technique than OSR, in that there is no need for open surgery, it may have advantages over OSR. In addition, some individuals with other medical illnesses, for whom open surgery may be considered a high‐risk procedure and who are not fit for OSR, can be offered EVAR instead.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2014

Minimally invasive versus surgical treatment of an aneurysm of the popliteal artery

The popliteal artery is a blood vessel situated behind the knee joint. Sometimes it weakens and expands like a balloon, known as an aneurysm. If left untreated, the blood clot within the aneurysm may embolise or the aneurysm may rupture or get blocked. Any of these complications can lead to limb loss or even death. Traditionally, popliteal artery aneurysm (PAA) has been treated surgically. However, it is also possible to treat the condition by deploying an endovascular stent graft through a small puncture in the groin. An endovascular stent graft is a fabric tube supported by a metal mesh which sits snugly and forms a seal within the artery. The success of the procedure is determined by the ability of the surgically applied graft or the stent graft to remain unblocked. Blockage of the graft decreases the leg circulation, which may require emergency surgery. Some consider the surgical technique to be the gold standard, although the feasibility of the endovascular technique has been well documented in many retrospective studies. Level‐1 evidence is only obtained however when two techniques are pitted against each other in a prospective randomised controlled trial (RCT).

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2014

Minimum surgery volumes in hospitals: Are the outcomes better in hospitals that do more operations?

There may be advantages to having surgery for a total knee replacement, for example, in a hospital with a higher volume of this operation. However, setting specific minimum volumes for operations in German hospitals is not simple.

Informed Health Online [Internet] - Institute for Quality and Efficiency in Health Care (IQWiG).

Version: May 10, 2011

Endovascular coiling versus neurosurgical clipping for patients with aneurysmal subarachnoid haemorrhage

Endovascular coiling of ruptured aneurysms in the brain leads to a better outcome than surgical clipping. Bleeding on the surface of the brain is called a subarachnoid haemorrhage. The bleeding usually comes from the rupture of a weak spot in an artery carrying blood to the brain. This weak spot is like a small balloon, or blister, which is called an aneurysm. The outcome after subarachnoid haemorrhage is generally poor: half the patients die within one month; and of those who survive the initial month, just under half remain dependent on someone else for help with activities of daily living such as walking, dressing, and bathing. One of the risks in patients with subarachnoid haemorrhage is rebleeding. There are two main ways to try to stop this: operative clipping of the neck of the aneurysm or blocking of the aneurysm from inside by endovascular coiling. This review shows that the number of people who survive and are independent in their daily living is higher after coiling than after clipping. The evidence comes mainly from one large trial.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2008

Drug treatment for small abdominal aortic aneurysms

An aneurysm is an abnormal localised widening (dilatation) of an artery. The most common place for such a dilatation is the abdominal aorta. This is the main artery linking the heart to the lower limbs and the organs of the abdomen, and a dilatation here is termed an abdominal aortic aneurysm (AAA). About 4% of men over 55 years of age have an AAA, but it is less common in women. Aneurysms over 55 mm in diameter carry a high risk of rupture, and rupture carries a high risk of death. To reduce the risks, screening programmes using ultrasound scanning have been introduced for selected groups in a number of countries. Patients with aneurysms over 55 mm are then evaluated for elective aneurysm repair. For aneurysms at or below the 55 mm cut‐off, the current treatment is 'watchful waiting', where the aneurysm is repeatedly scanned over time to see if it is enlarging. This review aimed to identify medical treatments which could slow or even reverse aneurysm growth, and thus delay or avoid the need for elective surgery.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2012

Surgery for small abdominal aortic aneurysms that do not cause symptoms

An aneurysm is a ballooning of an artery (blood vessel), which can happen in the major artery in the abdomen (aorta). The cause is unknown. Ruptured aneurysms cause death unless surgical repair is rapid, which is difficult to achieve. Surgery for patients with aneurysms more than 5.5 cm in diameter or who have associated pain is considered necessary to relieve symptoms and to reduce the risk of rupture and death, although there are risks associated with surgery. Surgical repair of the aneurysm consists of insertion of a prosthetic inlay graft either by open surgery or endovascular repair.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2012

Early versus delayed mobilisation to prevent further bleeding after spontaneous bleeding on the surface of the brain

Aneurysmal subarachnoid haemorrhage (SAH) is a serious event where spontaneous bleeding on the surface of the brain is usually caused by the rupture of an abnormal swelling of an artery (aneurysm). If effective treatment is not provided (e.g. surgery or drug therapy) rebleeding may occur, causing death or disability for the patient. Some researchers observed that the highest risk period for rebleeding in people with a SAH was between two and four weeks after symptom onset, if they did not receive effective treatment. Total bedrest for four to six weeks has, therefore, been considered to be one of the basic interventions to avoid rebleeding. However, despite comprehensive searching, we did not identify any suitable studies that provided evidence for or against staying in bed for at least four weeks after symptom onset in people who did not, or could not, have any treatment for their ruptured aneurysm. Treatment strategies to reduce the risk of rebleeding in SAH patients before aneurysm repair, or in those patients not suitable for surgical treatment, or who prefer conservative treatments, deserve further attention.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2013

Different stent graft types to repair thoracic aortic aneurysms

An aneurysm is a localised widening of an artery. The thoracic aorta is the largest artery in the body, delivering blood from the heart to the arms and head. If an aneurysm occurs in the thoracic aorta it can expand and may rupture, resulting in death. Open surgery can treat these aneurysms, which involves opening the chest and placing an artificial graft over the widening. A new alternative treatment involves an artificial stent graft, delivered through an arterial blood vessel in the groin, fixed over the widening. This technique is called endovascular repair. There are many different types of stent grafts available. They differ in how they are inserted into/access the blood vessel, how they attach to the walls of the artery and the design and materials they are made from. We searched for evidence directly comparing the different types of stent grafts in aneurysm repair. This review found no evidence from randomised controlled trials to determine if any specific stent graft performs better than another type of stent graft. More research is required to help surgeons decide which specific type of stent graft to use.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2013

Different stent grafts for repair of abdominal aortic aneurysms

An aneurysm is a localised widening of an artery. The abdominal aorta is the largest artery in the body, delivering blood from the heart to the organs in the abdomen and the legs. If an aneurysm occurs in the abdominal aorta it can expand and may rupture, resulting in death. Open surgery can treat these aneurysms; this involves opening the abdomen and placing an artificial graft over the widening. A new alternative treatment involves an artifical stent graft, delivered through an arterial blood vessel in the groin, fixed over the widening. This technique is called endovascular repair. There are many different types of stent graft available. They differ in how they are inserted in/access the blood vessel, how they attach to the walls of the artery and the design and materials they are made from. We searched for evidence directly comparing the different types of stent grafts in aneurysm repair. This review found no randomised controlled trial evidence investigating if any specific stent graft performs better than another type of stent graft. More research is required to help surgeons decide which specific type of stent graft to use.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2013

Skin puncture versus exposing the femoral artery for minimally invasive repairs of abdominal aortic aneurysms

Abdominal aortic aneurysms are a ballooning of the largest blood vessel in the abdomen, the abdominal aorta, due to weakness of the vessel wall. This ballooning may lead to life threatening rupture. Repair of the aneurysm is recommended if it is felt to pose a significant risk. All repairs involve putting in an artifical graft, a tube composed of fabric, to help reinforce the artery wall. There are two main methods for repair. One is an open technique in which the whole abdomen is opened and the graft is put inside the blood vessel. The other technique is an endovascular aneurysm repair. With this technique the graft is fed into the abdominal aorta through an artery in the groin (the femoral artery) and it avoids the large abdominal incision. This review looked at an alternative method for introducing the graft into the femoral artery, percutaneous access. Instead of making an incision in the groin to expose the femoral artery (a cut‐down), a small hole is made in the skin and then a needle with a plastic tube sitting over it is introduced into the femoral artery. Once introduced, the needle can be pulled back up the tube leaving the tube in place in the artery. The graft and all other materials can then be fed into the artery via the plastic tube. Once the procedure is complete the tube can be withdrawn. The surface incision can usually be closed with one stitch.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2014

Timing of surgery for aneurysmal subarachnoid haemorrhage

There is no evidence on the best time for surgical treatment of aneurysmal subarachnoid haemorrhage. Aneurysmal subarachnoid haemorrhage is a life‐threatening condition. It is due to the bursting of an aneurysm (a weakness in the wall of a blood vessel in the brain). This can be treated by a surgical operation to place a clip over the aneurysm neck. There is uncertainty about whether to perform the operation immediately, or to wait a few days. The review found only one randomised trial which assessed the effect of the timing of surgery. From the limited evidence available, the timing of surgery was not a critical factor in determining the outcome from an aneurysmal subarachnoid haemorrhage, but further research is needed.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2010

Treatments for coarctation of the thoracic aorta

Coarctation of the aorta (CoA) is a congenital narrowing of the lumen in a section of the aorta. The narrowing is most commonly in the upper thoracic aorta but can occur in the abdominal aorta. It is present at birth and males are more often affected than females. Clinical symptoms are variable and depend on the position, degree and extent of the narrowed segment of the aorta. Other congenital heart abnormalities may also be present. In general, the diagnosis is made by finding a difference in pulsations and blood pressure between the upper body and arms and the lower body and legs. If left unrepaired, average survival is 31 years. The treatment of CoA is intended to improve life expectancy and quality of life by reducing the incidence of aortic and cardiac disabling conditions such as aneurysm (dilation) of the ascending aorta, coronary artery disease, high blood pressure, and aortic and mitral valvular disease. The treatment of CoA consists of enlarging of the narrowed segment. Traditionally this required open heart surgery. Balloon angioplasty became available as an alternative treatment in the 1980s but recurrence, aneurysm and aortic dissection (a tear in the inner wall of the aorta causing blood to flow between the layers of the blood vessel wall) remained disadvantages of both treatments. In the early 1990s, endovascular stents were introduced and have become an alternative approach to surgical repair. The present review looked at the available evidence for the effectiveness of open surgery compared with placing a stent in the coarctation of the thoracic aorta. The review authors searched the medical literature but they did not found any studies that compared open surgery and stent placement for the treatment of coarctation of the thoracic aorta. The treatment of CoA is a challenging procedure and the centers that perform this treatment have a well‐established strategy for patients with CoA; the strategy is in accordance with the experience of involved professionals and local resources. In both situations experience and resources have improved the results of the treatment. However a more concrete and long‐term analysis of these strategies is needed.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2012

Cooling the brain during surgery for preventing death or severe disability in patients with brain aneurysms

Intracranial aneurysms are bulges on the cerebral arterial wall. Rupture of an intracranial aneurysm is often life‐threatening. Such patients are classified as good‐grade or poor‐grade based on their clinical manifestations. Surgery is a common option to treat this problem but it can cause further damage to the brain. Theoretically, intraoperative mild hypothermia reduces the metabolic activity of the brain thus protecting it during an operation. Research on animals supports this theory in general. We conducted a systematic review on clinical trials examining the effect of intraoperative mild hypothermia in preventing death and handicap in patients undergoing open‐skull surgery for cerebral aneurysms. We found only three randomised controlled trials with a total of 1158 patients for inclusion in the review. Data primarily came from one high‐quality study with 1000 patients. Our analysis showed that, for patients with good‐grade aneurysmal subarachnoid haemorrhage, intraoperative mild hypothermia may have the potential to prevent death or dependency in activities of daily living in a few of them. However, the effect cannot be proven statistically. Although no harm of intraoperative mild hypothermia was documented, this treatment should not be applied routinely. In patients with poor‐grade aneurysmal subarachnoid haemorrhage or without subarachnoid haemorrhage, the effect is unclear. A high‐quality randomised clinical trial of intraoperative mild hypothermia for postoperative neurological deficits in patients with poor‐grade aneurysmal subarachnoid haemorrhage might be feasible.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2012

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  • Aneurysm
    An aneurysm is an abnormal widening or ballooning of a portion of an artery due to weakness in the wall of the blood vessel.
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