We evaluate nationwide perioperative outcomes of complex EVAR and assess the volume-outcome association of complex EVAR.
Endovascular treatment with fenestrated (FEVAR) or branched (BEVAR) endografts ...is progressively used for excluding complex aortic aneurysms (complex AAs). It is unclear if a volume-outcome association exists in endovascular treatment of complex AAs (complex EVAR).
All patients prospectively registered in the Dutch Surgical Aneurysm Audit who underwent complex EVAR (FEVAR or BEVAR) between January 2016 and January 2020 were included. The effect of annual hospital volume on perioperative mortality was examined using multivariable logistic regression analyses. Patients were stratified into quartiles based on annual hospital volume to determine hospital volume categories.
We included 694 patients (539 FEVAR patients, 155 BEVAR patients). Perioperative mortality following FEVAR was 4.5% and 5.2% following BEVAR. Postoperative complication rates were 30.1% and 48.7%, respectively. The first quartile hospitals performed <9 procedures/yr; second, third, and fourth quartile hospitals performed 9-12, 13-22, and ≥23 procedures/yr. The highest volume hospitals treated the significantly more complex patients. Perioperative mortality of complex EVAR was 9.1% in hospitals with a volume of < 9, and 2.5% in hospitals with a volume of ≥13 (P = 0.008). After adjustment for confounders, an annual volume of ≥13 was associated with less perioperative mortality compared to hospitals with a volume of < 9.
Data from this nationwide mandatory quality registry shows a significant effect of hospital volume on perioperative mortality following complex EVAR, with high volume complex EVAR centers demonstrating lower mortality rates.
Purpose:
Octogenarians are known to have less-favorable outcomes following ruptured abdominal aortic aneurysm (rAAA) repair compared with their younger counterparts. Accurate information regarding ...perioperative outcomes following rAAA-repair is important to evaluate current treatment practice. The aim of this study was to evaluate perioperative outcomes of octogenarians and to identify factors associated with mortality and major complications after open surgical repair (OSR) or endovascular aneurysm repair (EVAR) of a rAAA using nationwide, real-world, contemporary data.
Methods:
All patients that underwent EVAR or OSR of an infrarenal or juxtarenal rAAA between January 1, 2013, and December 31, 2018, were prospectively registered in the Dutch Surgical Aneurysm Audit (DSAA) and included in this study. The primary outcome was the comparison of perioperative outcomes of octogenarians versus non-octogenarians, including adjustment for confounders. Secondary outcomes were the identification of factors associated with mortality and major complications in octogenarians.
Results:
The study included 2879 patients, of which 1146 were treated by EVAR (382 octogenarians, 33%) and 1733 were treated by OSR (410 octogenarians, 24%). Perioperative mortality of octogenarians following EVAR was 37.2% versus 14.8% in non-octogenarians (adjusted OR=2.9, 95% CI=2.8–3.0) and 50.0% versus 29.4% following OSR (adjusted OR=2.2, 95% CI=2.2–2.3). Major complication rates of octogenarians were 55.4% versus 31.8% in non-octogenarians following EVAR (OR=2.7, 95% CI=2.1–3.4), and 68% versus 49% following OSR (OR=2.2, 95% CI=1.8–2.8). Following EVAR, 30.6% of the octogenarians had an uncomplicated perioperative course (UPC) versus 49.5% in non-octogenarians (OR=0.5, 95% CI=0.4–0.6), while following OSR, UPC rates were 20.7% in octogenarians versus 32.6% in non-octogenarians (OR=0.5, 95% CI=0.4–0.7). Cardiac or pulmonary comorbidity and loss of consciousness were associated with mortality and major complications in octogenarians. Interestingly, female octogenarians had lower mortality rates following EVAR than male octogenarians (adjusted OR=0.7, 95% CI=0.6–0.8).
Conclusion:
Based on this nationwide study with real-world registry data, mortality rates of octogenarians following ruptured AAA-repair were high, especially after OSR. However, a substantial proportion of these octogenarians following OSR and EVAR had an uneventful recovery. Known preoperative factors do influence perioperative outcomes and reflect current treatment practice.
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NUK, OILJ, SAZU, UKNU, UL, UM, UPUK
OBJECTIVE:The aim of this was to analyze differences between saccular-shaped abdominal aortic aneurysms (SaAAAs) and fusiform abdominal aortic aneurysms (FuAAAs) regarding patient characteristics, ...treatment, and outcome, to advise a threshold for intervention for SaAAAs.
BACKGROUND:Based on the assumption that SaAAAs are more prone to rupture, guidelines suggest early elective treatment. However, little is known about the natural history of SaAAAs and the threshold for intervention is not substantiated.
METHODS:Observational study including primary repairs of degenerative AAAs in the Netherlands between 2016 and 2018 in which the shape was registered, registered in the Dutch Surgical Aneurysm Audit (DSAA). Patients were stratified by urgency of surgery; elective versus acute (symptomatic/ruptured). Patient characteristics, treatment, and outcome were compared between SaAAAs and FuAAAs.
RESULTS:A total of 7659 primary AAA-patients were included, 6.1% (n = 471) SaAAAs and 93.9% (n = 7188) FuAAAs. There were 5945 elective patients (6.5% SaAAA) and 1714 acute (4.8% SaAAA). Acute SaAAA-patients were more often female (28.9% vs 17.2%, P = 0.007) compared with acute FuAAA-patients. SaAAAs had smaller diameters than FuAAAs, in elective (53.0 mm vs 61 mm, P = 0.000) and acute (68 mm vs 75 mm, P = 0.002) patients, even after adjusting for sex. In addition, 25.2% of acute SaAAA-patients presented with diameters <55 mm and 8.4% <45 mm, versus 8.1% and 0.6% of acute FuAAA-patients (P = 0.000). Postoperative outcomes did not significantly differ between shapes in both elective and acute patients.
CONCLUSIONS:SaAAAs become acute at smaller diameters than FuAAAs in DSAA patients. This study therefore supports the current idea that SaAAAs should be electively treated at smaller diameters than FuAAAs. The exact diameter threshold for elective treatment of SaAAAs is difficult to determine, but a diameter of 45 mm seems to be an acceptable threshold.
The new 2019 guideline of the European Society for Vascular Surgery (ESVS) recommends consideration for elective iliac artery aneurysm (eIAA) repair when the iliac diameter exceeds 3.5 cm, as opposed ...to 3.0 cm previously. The current study assessed diameters at time of eIAA repair and ruptured IAA (rIAA) repair and compared clinical outcomes after open surgical repair (OSR) and endovascular aneurysm repair (EVAR).
This retrospective observational study used the nationwide Dutch Surgical Aneurysm Audit (DSAA) registry that includes all patients who undergo aorto-iliac aneurysm repair in the Netherlands. All patients who underwent primary IAA repair between 1 January 2014 and 1 January 2018 were included. Diameters at time of eIAA and rIAA repair were compared in a descriptive fashion. The anatomical location of the IAA was not registered in the registry. Patient characteristics and outcomes of OSR and EVAR were compared with appropriate statistical tests.
The DSAA registry comprised 974 patients who underwent IAA repair. A total of 851 patients were included after exclusion of patients undergoing revision surgery and patients with missing essential variables. eIAA repair was carried out in 713 patients, rIAA repair in 102, and symptomatic IAA repair in 36. OSR was performed in 205, EVAR in 618, and hybrid repairs and conversions in 28. The median maximum IAA diameter at the time of eIAA and rIAA repair was 43 (IQR 38-50) mm and 68 (IQR 58-85) mm, respectively. Mortality was 1.3% (95% CI 0.7-2.4) after eIAA repair and 25.5% (95% CI 18.0-34.7) after rIAA repair. Mortality was not significantly different between the OSR and EVAR subgroups. Elective OSR was associated with significantly more complications than EVAR (intra-operative: 9.8% vs. 3.6%, post-operative: 34.0% vs. 13.8%, respectively).
In the Netherlands, most eIAA repairs are performed at diameters larger than recommended by the ESVS guideline. These findings appear to support the recent increase in the threshold diameter for eIAA repair.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
To evaluate single center results with selective use of the Gore Excluder stent-graft for elective abdominal aortic aneurysm repair.
Retrospective analysis of a prospective data base. Primary ...endpoints were technical success, all-cause and aneurysm-related mortality and aneurysm rupture. Secondary endpoints were late complications including migration, endoleak, aneurysm growth, limb occlusion, and re-intervention.
The Gore Excluder stent-graft was used in 92 elective cases, mainly in cases with difficult iliac anatomy. There were 81 (88%) male patients. Mean age was 70.4+/-7.5 (range, 53-87). Primary assisted technical success rate was 98.9% (91/92 patients). Thirty-day mortality was 0%. Median follow-up was 35.7 months (range, 2-99). Overall survival was 95.2+/-2.4% at 1 year, 89.2+/-3.7% at 2 years, 83.9+/-4.5% at 3 years and 70.2+/-6.8% at 5 years. During follow-up there were 3 (3.3%) Type I endoleaks and 20 (21.7%) Type II endoleaks. Proximal migration of more than 5 mm without endoleak occurred in two patients. In total 13 re-interventions were performed in 12 (13%) patients. No graft limb occlusion occurred. No aneurysm ruptured during follow-up.
Selective use of the Gore Excluder demonstrates excellent short- and long-term results. Despite being used in challenging iliac anatomy no graft limbs occluded.
Abstract
North Minahasa Regency is a corn development area in North Sulawesi, but its production is still low. The aim of the research is to obtain data on corn production systems and their ...development policies. Survey and FGD data collection techniques. Implementation February - March 2020. Analysis of quantitative data using multiple linear regression. The results showed that farmers are starting to use new superior varieties that have higher potential than local varieties, but the use of cultivation technology is still in accordance with farmers’ habits. The results of the coefficient test, the results of the t test or the sig probability value show that the area of land and labor has a calculated t value of 2.532 and 2.221; bigger than t table (2.064). This means that the variable land area and labor have a significant effect on corn production at α 5%. The potential for the development of this commodity is quite promising, but it is necessary to increase production referring to cultivation technology and product diversification.
The aim of the Endurant for Challenging Anatomy: Global Experience (EAGLE) registry is to evaluate prospectively the technical and clinical success rate of a stentgraft used in patients with ...challenging neck anatomy outside the instructions for use (IFU) but within objective anatomical limits.
This was a prospective, international, multicentre, observational study. From 1 February 2012 to 1 September 2017, patients with an abdominal aortic aneurysm with a challenging infrarenal neck that were deemed suitable for endovascular aneurysm repair were included prospectively at 23 European centres. Patients were distributed by anatomy into three groups: short neck (SN; infrarenal neck 5 – 10 mm in combination with suprarenal angulation α ≤ 45° and infrarenal angulation β ≤ 60°); medium neck (MN; infrarenal neck 10 – 15 mm with α ≤ 60° and β 60° – 75° or α 45°– 60° and β ≤ 75°; and long angulated neck (LN; infrarenal neck ≥ 15 mm with α ≤ 75° and β 75°– 90° or α 60°– 75° and β ≤ 90°. All computed tomography scans were reviewed by an independent core laboratory. Primary outcomes were technical and clinical success. Secondary endpoints were peri-operative major adverse events, all cause mortality, aneurysm related mortality, endoleaks, migration, and secondary intervention.
One hundred and fifty patients (81.3% male) were included (SN = 55, MN = 16, LN = 79). The median follow up was 36 ± 12.6 months. In the overall cohort, the technical success rate was 93.3%. Estimated freedom from aneurysm related death was 97.3% at three years. Freedom from secondary interventions was 84.7% at three years. Estimated clinical success was 96.0%, 90.8%, and 83.2% at 30 days, one year, and three years, respectively. Estimated freedom from all cause mortality, late type IA endoleak, and migration at three years was 75.1%, 93.7%, and 99.3%, respectively.
The early and midterm results of the EAGLE registry show that endovascular repair with the Endurant stentgraft in selected patients with challenging infrarenal neck anatomy yields results in line with large “real world” registries. Long term results are awaited for more definitive conclusions.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
The sharp decrease in open surgical repair (OSR) for abdominal aortic aneurysm (AAA) has raised concerns about contemporary postoperative outcomes. The study was designed to analyse the impact of ...complications on clinical outcomes within 30 days following OSR.
Patients who underwent OSR for intact AAA registered prospectively between 2016 and 2019 in the Dutch Surgical Aneurysm Audit were included. Complications and outcomes (death, secondary interventions, prolonged hospitalization) were evaluated. The adjusted relative risk (aRr) and 95 per cent confidence intervals were computed using Poisson regression. Subsequently, the population-attributable fraction (PAF) was calculated. The PAF reflects the expected percentage reduction of an outcome if a complication were to be completely prevented.
A total of 1657 patients were analysed. Bowel ischaemia and renal complications had the largest impact on death (aRr 12·44 (95 per cent c.i. 7·95 to 19·84) at PAF 20 (95 per cent c.i. 8·4 to 31·5) per cent and aRr 5·07 (95 per cent c.i. 3·18 to 8.07) at PAF 14 (95 per cent c.i. 0·7 to 27·0) per cent, respectively). Arterial occlusion had the greatest impact on secondary interventions (aRr 11·28 (95 per cent c.i. 8·90 to 14·30) at PAF 21 (95 per cent c.i. 14·7 to 28·1) per cent), and pneumonia (aRr 2·52 (95 per cent c.i. 2·04 to 3·10) at PAF 13 (95 per cent c.i. 8·3 to 17·8) per cent) on prolonged hospitalization. Small effects were observed on outcomes for other complications.
The greatest clinical impact following OSR can be made by focusing on measures to reduce the occurrence of bowel ischaemia, arterial occlusion and pneumonia.
Abstract
Subsistent/semi commercial farmers were very slow to adopt the new technology of maize cultivation, although the new introduction technology could be done by farmers, economies and ...compatible with farmer’s socio-culture. Generally, that was caused introduction technology need high inputs (i.e. superior seed maize varieties, fertilizer, and pesticides), and other sides orientation of maize cultivation by subsistent/semi commercial farmers for food security, farmers limited money to bought inputs, and inputs shop in sub district/village levels was nothing. The consequence was introduction of new technology could not extend and farmers back to existing technology after character building had finished. The research was conducted on 3 (three) farmer’s group and planted area 15 hectares of maize in South Timor Tengah district, East Nusa Tenggara province in 2017-2018. The research showed the problems could be overcome by guiding of new technology to farmers/farmer’s group among 1-2 times planting and building of new institutional i.e. clinic of technology on village level. Extension workers and group of farmer’s group (GAPOKTAN) manage clinic of technology. The clinic function was to inform new agricultural information to farmers/farmer’s group and be responsibility to supplying of inputs. To guarantee the continuity maize farming system, farmers need loan assistance with semi grand system. Farmers/farmers group borrow inputs from the clinic of technology and it refund by maize product after harvesting. The clinic of technology did maize processing and sold maize in early rainy season. The clinic of technology built maize seed industry unit in village level and bought inputs (fertilizer and pesticides Farmer’s household lack of food, although improving of technology cultivation in ENT province had done) from agricultural shop on district/province level. This strategy could guarantee sustainability maize farming system and potential to develop in other village.
The abundance of agricultural products often causes environmental problems. The utilization of agricultural waste from carrots can reduce both the feed cost and environmental pollution and become a ...source of vitamin A for the health of the native chicken. The study aims to analyze carrot (
L.) waste juice on native chicken performance. It was conducted from April to July 2019 at Pandu experimental field in North Minahasa Regency. The practical method used was a completely randomized design with four replications. The experimental livestock used in the study was 80-day-old chickens of native chicken. The concentration of carrot juice during the study was as follows: 100% drinking water without carrot juice (W0), 80% water drinking + 20% carrot juice (W1), 60% drinking water + 40% carrot juice (W2), and 20% drinking water + 80% carrot juice (W3). Observed variables included feed intake, body weight gain, feed conversion ratio (FCR), and mortality rate. The results showed that carrot waste juice significantly impacted the body weight gain, feed conversion rate, and 0% mortality rate during the 8 weeks. The concentration of 20% drinking water + 80% carrot juice (W3) with the feed intake ratio of 1.608 g, body weight gain value of 775.63 ± 301 g, and the FCR of 2.1 ± 0.06. However, the consumption ratio did not differ among treatments. The addition of carrot waste juice, as much as 80%, in the drinking water of native chickens showed an increase in body weight compared to other treatments. In conclusion, the current study showed that treatment of carrot waste juice has a significant effect on body weight in 8 weeks of maintenance. Meanwhile, the feed intake ratio of carrot waste juice treatment has no real effect. There was no dead chicken (0%) in the present study. The carrot waste juice can be used in chicken drinks 40–80% by paying attention to the balance of energy content and feed proteins used to grow chickens.
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