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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

The use of fenestrated and branched endovascular aneurysm repair for juxtarenal and thoracoabdominal aneurysms: a systematic review and cost-effectiveness analysis

The study found that it was not possible to conduct a cost-effectiveness analysis for treating abdominal aortic aneurysms using fenestrated/branched endovascular repair versus conventional treatment (open repair surgery/no surgery) because of a lack of clinical effectiveness data. Future clinical trials are required to obtain the necessary data.

Health Technology Assessment - NIHR Journals Library.

Version: December 2014
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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

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.

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

Version: 2016

Calculating when elective abdominal aortic aneurysm repair improves survival for individual patients: development of the Aneurysm Repair Decision Aid and economic evaluation

This study found the use of the Aneurysm Repair Decision Aid (ARDA) provides detailed information on the potential consequences of abdominal aortic aneurysm repair or a decision not to repair that may be helpful to vascular surgeons and their patients in reaching informed decisions. The economic evaluation suggests that using the ARDA compared with current guidelines could be cost-effective but there is a high level of uncertainty.

Health Technology Assessment - NIHR Journals Library.

Version: April 2015
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Endovascular versus conventional medical treatment for chronic type B aortic dissection (a tear in the lining of the aortic artery)

Aortic dissection is a potentially life‐threatening condition that occurs when a tear in the inner lining of the aorta (usually in the chest portion of the artery) causes bleeding between the inner and outer layers of the wall of the aorta. The layers become separated (or dissected) creating a false channel for blood to flow. It is the most common emergency affecting the aorta. Symptoms include sudden, severe, sharp chest pain that spreads to the neck or down the back, sudden difficulty speaking, a weak pulse and loss of consciousness. Aortic dissections typically occur in adults aged between 60 and 70 years, with more males than females. The main cause is thought to be high blood pressure. An aortic dissection is classified depending on where it begins in the aorta and if it is acute or chronic. Acute dissections are diagnosed within 14 days after the first symptoms appear; while chronic ones are diagnosed after 14 days. This review looked at chronic type B dissections, which begin in the descending part of the aorta (the section of the artery that moves down through the chest and abdomen). Patients with this type of aortic dissection have traditionally been treated with blood pressure lowering medications, with good short‐term results (annual survival in excess of 80%). They have, however, increased long‐term mortality. In the long term, medical treatment alone may put some patients at risk of serious complications such as progressive aortic enlargement, poor blood flow to some organs or the extremities, and aortic rupture. Patients with these life‐threatening complications require urgent treatment of the dissected aorta by open surgery or, more recently, endovascular thoracic aortic stent grafting (TEVAR). TEVAR reduces the number of early deaths compared with open surgical treatment.

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

Version: 2012

Primary Care Screening for Abdominal Aortic Aneurysm: A Systematic Evidence Review for the U.S. Preventive Services Task Force [Internet]

To assess the benefits and harms of AAA screening programs and approaches to treating small aneurysms, and to determine screening yield for subgroup populations.

Evidence Syntheses - Agency for Healthcare Research and Quality (US).

Version: January 2014
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Controlled hypotension versus normotensive resuscitation strategy for people with ruptured abdominal aortic aneurysm

An abdominal aortic aneurysm (AAA) is a swelling (aneurysm) of the aorta, the main blood vessel that leads away from the heart and through the abdomen to the rest of the body. It can develop in both men and women. A growing aneurysm can burst (rupture), which leads to massive blood loss and shock. It is frequently fatal and accounts for the death of at least 45 people per 100,000 population.

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

Version: 2016

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

Revascularisation of the left subclavian artery for thoracic endovascular aortic repair

The thoracic aorta is the largest blood vessel in the chest. It originates from the heart and supplies blood to the whole body. It can be affected by several diseases, including an aneurysm, which is an enlargement of a weakened section of the aorta, and dissection, which occurs when a tear in the aortic lining causes blood to flow between the layers of the wall of the aorta, forcing the layers apart. The traditional treatment of these conditions is open surgical repair. Thoracic endovascular aortic repair (TEVAR) has evolved as an alternative treatment for a wide variety of aortic diseases. It is less invasive than open surgery, and involves inserting an artificial graft (a tube composed of fabric) into the thoracic aorta through an artery in the groin (the femoral artery), to help reinforce the aortic wall. A significant proportion of patients with thoracic aortic disease have abnormalities close to, or involving the origin of the left subclavian artery (LSA; one of the branches of the thoracic aorta). In these situations, the aortic stent graft needs to be placed close to the LSA, thereby blocking the blood vessel opening. This can potentially result in reduced blood supply to the brain and spinal cord, causing stroke and spinal cord ischaemia (spinal cord stroke). This review aimed to look at the value of a surgical bypass, which can provide an alternative route for blood supply (revascularisation) to the brain and spinal cord in cases of TEVAR, where the LSA is covered.

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

Version: 2016

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.

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

Version: 2015

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.

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

Version: 2015

Fenestrated endovascular aneurysm repair

BACKGROUND: Fenestrated endovascular aneurysm repair (FEVAR) is a technically challenging operation. The duration, blood loss, and risk of limb ischaemia, contrast-induced nephropathy and reperfusion injury are likely to be higher than after standard endovascular aneurysm repair (EVAR). Benefits of FEVAR over open repair may be less than those seen with standard infrarenal EVAR. This paper is a meta-analysis of observational studies of all published data for FEVAR, with the aim to highlight current issues around the evidence for the potential benefit of FEVAR.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2012

Magnetic resonance imaging is more sensitive than computed tomography angiography for the detection of endoleaks after endovascular abdominal aortic aneurysm repair: a systematic review

OBJECTIVES: The purpose of this systematic review was to examine whether magnetic resonance imaging (MRI) or computed tomography angiography (CTA) is more sensitive for the detection of endoleaks in patients with abdominal aortic aneurysm (AAA) after EVAR.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2013

Effect of transarterial embolization on persistent type II endoleaks after endovascular aneurysm repair: a meta-analysis

OBJECTIVE: To evaluate the clinical effectiveness of transarterial embolization in persistent type II endoleak after endovascular aneurysm repair (EVAR).

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2008

Can an accessory renal artery be safely covered during endovascular aortic aneurysm repair?

A best evidence topic was constructed according to a structured protocol. The question addressed was whether coverage of an accessory renal artery (ARA) in patients undergoing endovascular aortic aneurysm repair (EVAR) is associated with increased risk of renal impairment. Altogether, 106 papers were located using the reported searches, of which 5 represented the best evidence to answer the question. The authors, journal, date and country of publication, study type, patient group studied, relevant outcomes parameters and results of these papers are tabulated. Our best evidence analysis included 116 patients who had one or more ARA excluded during EVAR. Segmental renal infarction occurred in varying numbers of patients (ranging from 0 to 84%). The authors consistently demonstrate that loss of renal mass is not associated with functional renal impairment, expressed by various outcome parameters such as serum creatinine, glomerular filtration rate (GFR), renal failure requiring dialysis and worsening hypertension. Comparisons of groups of patient with covered or preserved ARAs by one of the selected studies showed no difference in any of these renal outcome parameters, apart from a significantly higher renal infarct volume in the former group (P < 0.001). Subgroup analysis of patients with pre-existing renal dysfunction (GFR < 60 ml/h/m(2)) showed no difference in GFR change when comparing covered with uncovered ARA patient cohorts. No type II endoleak related to the covered ARA was reported in any of these studies. In conclusion, current evidence supports the safety of coverage of ARAs located in the proximal fixation zone to achieve seal in EVAR.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2013

A systematic review and meta-analysis indicates underreporting of renal dysfunction following endovascular aneurysm repair

Deterioration in renal function has been described after endovascular repair of abdominal aortic aneurysms (EVRs). The etiology is multifactorial and represents an important therapeutic target. A need exists to quantitatively summarize incidence and severity of renal dysfunction after EVR to allow better-informed attempts to preserve renal function and improve life expectancy. Here a systematic search was performed using Medline and Embase for renal function after EVR applying PRISMA statements. Univariate and multivariate random-effects meta-analyses were performed to estimate pooled postoperative changes in serum creatinine and creatinine clearance at four time points after EVR. Clinically relevant deterioration in renal function was also estimated at 1 year or more after EVR. Pooled probability of clinically relevant deterioration in renal function at 1 year or more was 18% (95% confidence interval of 14-23%, I2 of 82.5%). Serum creatinine increased after EVR by 0.05 mg/dl at 30 days/1 month, 0.09 mg/dl at 1 month to 1 year, and 0.11 mg/dl at 1 year or more (all significant). Creatinine clearance decreased after EVR by 5.65 ml/min at 1 month-1 year and by 6.58 ml/min at 1 year or more (both significant). Thus, renal dysfunction after EVR is common and merits attention.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2014

A meta-analysis of outcomes of endovascular abdominal aortic aneurysm repair in patients with hostile and friendly neck anatomy

BACKGROUND: An increasing number of abdominal aortic aneurysms with unfavorable proximal neck anatomy are treated with standard endograft devices. Skepticism exists with regard to the safety and efficacy of this practice.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2013

Endovascular repair for ruptured abdominal aortic aneurysm confers an early survival benefit over open repair

BACKGROUND: Despite the intuitive advantages of endovascular repair (EVAR) of ruptured abdominal aortic aneurysms (AAAs), uncertainty remains about the optimal management in the absence of convincing high-quality evidence. Our objective was to undertake a comprehensive literature review and perform a meta-analysis of outcome data of treatment modalities for ruptured AAAs.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2013

Endovascular aortic aneurysm repair in patients with hostile neck anatomy

PURPOSE: To report a systematic review and meta-analysis of outcomes following endovascular aneurysm repair (EVAR) in patients with hostile neck anatomy (HNA) vs. those with favorable neck anatomy (FNA).

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2013

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