Predicting Early Mortality after Thoracic Endovascular Aneurysm Repair: A Machine Learning-Based Decision Tree Analysis.

Background Esophageal atresia (EA) is associated with mortality, despite significant advances in neonatal care. Predictors of early mortality (EM) are well described in the literature. However, little is known about late mortality (LM). This study aimed to describe EM and LM rates and their associations in EA patients. Methods Patients with EA, managed at The Royal Children's Hospital, Melbourne (1980–2017), who subsequently died, were identified from the Nate Myers Esophageal Atresia database. Data collected included patient demographics, VACTERL associations, mortality risk factors, and preoperative, operative, and postoperative findings. Early mortality was defined as death during initial admission. Results A total of 90/628 (14.3%) patients died during the study period—EM occurred in 68/90 (75.6%), whilst LM occurred in 22/90 (24.4%). Causes of EM were most often palliation for respiratory anomalies (17/68, 25.0%), followed by associated syndromes (11/68. 16.2%) and neurological anomalies (10/68, 14.7%). The most commonly associated syndrome leading to palliation was trisomy 18 (7/68, 10.3%). Causes of LM were most often respiratory compromise (6/22, 27.3%), sudden unexplained deaths (6/22, 27.3%), and Fanconi's anemia (2/22, 9.1%). Of patients discharged from hospital, 22/560 (3.9%) subsequently died. There was no difference in VACTERL association between EM (32/63, 50.8%) and LM (11/20, 55%) (P = 0.80), and no difference in the incidence of twins between EM (8/58, 13.8%) and LM (2/18, 11.1%) (P = 1). Conclusion We identified predictors of early and late mortality in esophageal atresia in a large cohort. Parents of children with esophageal atresia must be counseled appropriately as to the likelihood of death following discharge from hospital.

Thoracic aortic aneurysms (TAAs) are an increasingly prevalent pathology with significant associated morbidity and mortality. Thoracic endovascular aortic repair (TEVAR) is the primary line of treatment. The purpose of this study was to analyse a single center's experience in the treatment of TAAs and identify possible risk factors for worse outcomes. A retrospective review of our institutional database was done to identify all patients treated for TAAs in a 10-year period, from 1 January 2012 to 31 December 2022. Data were extracted from patients' medical records. Primary outcome was all-cause mortality and secondary outcomes were procedure related morbidity (vascular access complications, medullary ischaemia, stroke, endoleaks, migration, aneurysm sac enlargement >5mm) and need for reintervention at 1-, 6- and 12-month follow-up. A descriptive and inferential analysis of the data was performed. Statistical analyses were conducted using the IBM Statistical Package for Social Sciences (SPSS) software. We identified 34 patients treated for TAAs in this period. Mean age was 68years [47-87] and 79.4% of patients were male. Mean aneurysm diameter was 63mm [35-100], 55.9% fusiform and 44.1% saccular. The majority (91.2%) were located at the descending thoracic aorta and 3 (8.8%) of them extended to the aortic arch. The most common aetiology was degenerative in 22 patients (64.7%), followed by aortic dissection in 8 patients (23.5%). Elective surgery was performed in 19 (61.3%) patients and 12 (38.7%) had urgent repair. TEVAR was the treatment of choice in 24 (77.4%) patients, and the remaining 7 (22.6%) were treated with hybrid surgery. Mean length of hospital stay was 10days [2-80] (6 days for elective repair versus 16days for urgent repair, p = .016). Follow-up period ranged from 1month to 10years. At 1 year follow-up, all-cause mortality was 15%, morbidity was 30% (with 6 (22%) patients having a type Ia endoleak) and need for reintervention was 22%. Aneurysm diameter was a significant risk factor for procedure related morbidity (median diameter of 73.5mm versus 56.0mm in patients with no morbidity; p = .027). The presence of type Ia endoleak was significantly associated with higher reintervention rates (p = .001), but not with higher mortality rates (p = .515). Age, female sex, aetiology and urgent repair weren't associated with any significant differences in the outcomes. TEVAR proved to be effective in the treatment of TAAs, with good outcomes at short and mid-term follow-up. TAAs should be diagnosed earlier and be promptly treated when meeting criteria to prevent worse outcomes.

Patients with low ejection fraction (EF) undergoing coronary artery bypass grafting (CABG) usually have a higher incidence of mortality and morbidity. In this retrospective study, we sought to detect significant preoperative predictors of early mortality in these patients. Patients with an EF of ≤ 30% who underwent isolated CABG in Catharina Hospital, Eindhoven, the Netherlands, between January 1998 and December 2008 (n = 413) were included in this study. All the preoperative patient-related risk factors were entered into a logistic regression analysis model to detect the significant predictors of early mortality. Patients with an EF of ≤ 30% represent 4.1% of the whole CABG population. The overall early mortality in this patient group was 9.1%. Risk factors for early mortality as identified by the univariate analysis were age, chronic obstructive pulmonary disease (COPD), prior CABG, New York Heart association (NYHA) class, emergency operation, preoperative serum creatinine (SeCr), and preoperative hemoglobin (Hb) level. These factors were entered into the multivariate analysis and were all identified as independent risk factors for early mortality. This study confirmed the impact of some well-known preoperative risk factors on early outcome in patients with low EF undergoing CABG. In addition, we have shown the predictive value of preoperative SeCr and hemoglobin level that have not yet been described.

Background: Endovascular treatment of aortic aneurysm is associated with an increase in pulse wave velocity (PWV) after surgery. However, the effect of different types of endovascular devices on PWV at different sites of the thoracic aorta remains unclear.Objectives: The purposes of this study were (1) to investigate the changes in PWV after endovascular treatment of thoracic aortic aneurysm; (2) to evaluate whether there is a difference in the changes in PWV at different treatment sites; and (3) to evaluate the effect of treatment length on changes in PWV.Methods: From July 2008 to July 2021, 276 patients underwent endovascular treatment of the true thoracic aortic aneurysm. Of these patients, 183 patients who underwent preoperative and postoperative PWV measurement within 1 year of surgery were included in the study. The treatment length index was calculated by treatment length divided by the height of the patients.Results: Five different types of endovascular devices were used (Najuta, Kawasumi Laboratories, Inc., Tokyo, Japan; TAG, W.L. Gore & Associates, Inc., AZ, USA; Relay, Bolton Medical, Inc., FL, USA; Talent/Valiant, Medtronic, MN, USA; and Zenith, Cook Medical, IN, USA). There was no significant change in PWV in patients receiving Najuta (Before: 2,040 ± 346.8 cm/s vs. After: 2,084 ± 390.5 cm/s, p = 0.14). However, a significant increase was observed in other devices: TAG (Before: 2,090 ± 485.9 cm/s vs. After: 2,300 ± 512.1 cm/s, p = 0.025), Relay (Before: 2,102 ± 465.3 cm/s vs. After: 2,206 ± 444.4 cm/s, p = 0.004), Valiant (Before: 1,696 ± 330.2 cm/s vs. After: 2,186 ± 378.7 cm/s, p < 0.001), and Zenith (Before: 2,084 ± 431.7 cm/s vs. After: 2,321 ± 500.6 cm/s, p < 0.001). There was a significant increase in PWV in patients treated from aortic arch (Before: 2,006 ± 333.7 cm/s vs. After: 2,132 ± 423.7 cm/s, p < 0.001) and patients treated from descending thoracic aorta (Before: 2,116 ± 460.9 cm/s vs. After: 2,292 ± 460.9 cm/s, p < 0.001). Multivariate analysis showed that treatment site was not an independent factor associated with changes in PWV. However, Najuta (Coef −219.43, 95% CI −322.684 to −116.176, p < 0.001) and treatment index (Coef 147.57, 95% CI 24.826 to 270.312, p = 0.019) were independent factors associated with changes in PWV.Conclusion: Najuta did not show a significant increase in PWV, while other commercially available devices showed a significant increase. The treatment site did not have a different effect on PWV. However, the treatment length was an independent factor associated with an increase in PWV.

ObjectivesWe report a multicenter experience of urgent late open conversion (LOC), with the goal of identifying the mode of presentation, technical aspects, and outcomes of this cohort of patients. MethodsA retrospective analysis of endovascular aneurysm repair (EVAR) requiring LOC (>30 days after implantation) from 1996 to 2016 in six vascular centers was performed. Patients with aneurysm rupture or other conditions requiring urgent surgery (<24 hours) were included. Patient demographics, time interval between EVAR and LOC, endograft characteristics, previous attempts at endovascular correction, indications, operative technique, 30-day mortality and morbidity, and long-term survival were analyzed. ResultsThere were 42 patients (88.1% men; mean age, 75.8 ± 9.0 years) included. Among the 42 explanted grafts, 33 were bifurcated, 1 tube, 6 aortouni-iliac, and 2 side-branch devices. Suprarenal fixation was present in 78.6%. Twelve patients (28.6%) underwent endovascular reintervention before LOC. Indications for urgent LOC were aneurysm rupture in 24 of the 42 cases (57.1%), endograft infection in 11 (26.2%), endoleak associated with aneurysm growth and pain in 6 (14.3%), and recurrent endograft thrombosis in 2 (4.8%). The proximal aortic cross-clamping site was infrarenal in 38.1% of cases, suprarenal in 19.1%, and supraceliac in 42.9%. Complete removal of the endograft was performed in 32 patients (76.2%) and partial removal in 10 (proximal preservation in 7 of 10). Reconstructions were performed with Dacron grafts in 33 of the 42 cases, cryopreserved arterial allografts in 5, and endograft removal associated with prosthetic axillobifemoral bypass in 4. The 30-day mortality was 23.8%; hemorrhagic shock was an independent risk factor of early mortality (odds ratio, 10.5; 95% confidence interval, 1.5-73.7; P = .018). During a mean follow-up of 23.9 ± 36.0 months, two late aneurysm-related deaths occurred. The estimated 1- and 5-year survival rates were 62.1% and 46.1%, respectively. ConclusionsUrgent LOC after EVAR are associated with high postoperative mortality rates and poor long-term survival. Further studies are necessary to define the timing and the best treatment option for failing EVAR.

Risk Modeling to Optimize Patient Selection for Management of the Descending Thoracic Aortic Aneurysm

Clinical impact of proximal fixation augmentation using the Najuta thoracic fenestrated stent graft during endovascular treatment for distal aortic arch aneurysm

Outcomes After Endovascular or Open Repair for Degenerative Descending Thoracic Aortic Aneurysm Using Linked Hospital Data

Emergency admissions from nursing homes (NHs) are associated with high mortality. Understanding the predictors of early mortality in these patients may guide clinicians in choosing appropriate site and level of care. We identified all consecutive admissions from NHs (all ages) to an Acute Medical Assessment Unit between January 2005 and December 2007. Analysis was performed at the level of the admission. The predictors of in-patient mortality at 7 days were examined using a generalized estimating equations analysis. A total of 314 patients [32% male, mean age: 84.2 years (SD: 8.3 years)] were admitted during the study period constituting 410 emergency episodes. Twenty-three percent of admissions resulted in hospital mortality with 73% of deaths occurring within 1 week (50% within the first 3 days). For 7-day mortality outcome, patients with a modified early warning score (MEWS) of 4-5 on admission had 12 times the odds of death [95% confidence interval (CI) 1.40-103.56], whereas those with a score of ≥6 had 21 times the odds of death (95% CI 2.71-170.57) compared with those with a score of ≤1. An estimated glomerular filtration rate (eGFR) of 30-60 and <30 ml/min/m(2) was associated with nearly a 3-fold increase in the odds of death at 1 week (95% CI 1.10-7.97) and a 5-fold increase in the odds of death within 1 week (95% CI 1.75-14.96), respectively, compared with eGFR > 60 ml/min/m(2). C-reactive protein (CRP) >100 mg/l on admission was also associated with a 2.5 times higher odds of death (95% CI 1.23-4.95). Taking eight or more different medication items per day was associated with only a third of the odds of death (95% CI 0.09-0.98) compared with patients taking only three or fewer per day. In acutely ill NH residents, MEWS is an important predictor of early hospital mortality and can be used in both the community and the hospital settings to identify patients whose death maybe predictable or unavoidable, thus allowing a more holistic approach to management with discussion with patient and relatives for planning of immediate care. In addition, CRP and eGFR levels on admission have also been shown to predict early hospital mortality in these patients and can be used in conjunction with MEWS in the same way to allow decision making on the appropriate level of care at the point of hospital admission.

Objective To explore the experience and management of intraoperative care of patients with aneurysm of thoracic aorta and aortic dissecting aneurysm treated with endovascular aneurysm repair and blood vessel bypass (the hybrid operation). Methods Ten patients with aneurysm of thoracic aorta and aortic dissecting aneurysm were treated with the hybrid operation in catheter lab. During the operation, nurses and doctors cooperated connivantly. Following measures were carried out to ensure the smooth operation and prevent the occurrence of complications: life signs were monitored carefully and medicines and equipments were prepared fully. Results 10 patients with aneurysm of thoracic aorta and aortic dissecting aneurysm underwent the hybrid operation successfully without no complications. Conclusions It was safe and effective to carry out the hybrid operation for patients with aneurysm of thoracic aorta and aortic dissecting aneurysm by strict management and specialist nurses raining. Skilled collaboration and strict life signs monitoring was pivotal to ensure the success of the hybrid operation. Key words: Thoracic aorta aneurysm; Aortic dissecting aneurysm; Endovascular aneurysm repair; Hybrid operation; Intervention nursing management

Risk factors for early and late mortality in surgical treatment of coronary artery disease

BackgroundRisks of predicting time-related in-hospital mortality varies in pelvic trauma patients. We aim to identify potential independent risks predictive of time-related (early versus late) mortality among pelvic trauma patients.MethodsLocal trauma registry data from 2004 through 2013 were reviewed. Mortality causes and timing of death were investigated. Multivariate logistic regression identified independent risks predictive of early versus late mortality in pelvic trauma patients while adjusting for patient demographics (age, sex, race), clinical variables (initial vital signs, mental status, injury severity, associated injuries, comorbidities), and hospital outcomes (surgical interventions, crystalloid resuscitations, blood transfusions).ResultsWe retrospectively collected data on 1566 pelvic trauma patients with a mortality rate of 9.96 % (156/1566). Approximately 74 % of patients died from massive hemorrhage within the first 24 h of hospitalization (early mortality). Revised trauma score (RTS), injury severity score (ISS), initial hemoglobin, direct transfer to operating room, and blood transfusion administration in the Emergency Department were considered independent risk factors predictive of early mortality. Age, ISS, and Glasgow Coma Scale (GCS) were deemed risk factors predictive of death after 24 h (late mortality).DiscussionGiven the fact of a substantial number of patients died within the first 24 h of hospital arrival, it is reasonable to consider the first 24 h of hospitalization as the appropriate window within which early mortality may be expected to occur in pelvic trauma patients. The risk factors associated with massive hemorrhage were strong predictors of early mortality, whereas late mortality predictors were more closely linked with comorbidities or in-hospital complications.ConclusionsWhile risk factors predictive of early versus late mortality vary, ISS seems to predict both early and late mortality accurately in pelvic trauma patients.

Recent years have witnessed the emergence of novel technologies that enable less invasive endovascular treatment of descending thoracic aortic disease (TAD). This has occurred against a backdrop of improved identification of various disease processes and better results with open surgical repair. The natural history of the specific acute aortic syndromes that affect the descending thoracic aorta has also been described with more clarity and has become more commonly recognized. This is in part secondary to the widespread availability and application of advanced imaging technologies that permit precise diagnoses. As data are accumulating, these pathological processes involving the descending thoracic aorta are no longer thought of as simply variants of one another but as distinct entities with well-defined clinical behavior. As the technology for endovascular repair continues to mature and its utilization increases, there is a need for a careful assessment of the current state of medical management, traditional open therapy, and evolving endovascular treatment of distinct thoracic aortic pathologies. The purpose of this scientific statement is to present a contemporary review of the various pathological processes that affect the descending thoracic aorta: Aneurysms, dissections, intramural hematomas (IMHs), penetrating atherosclerotic ulcers (PAUs), and aortic transections. These disorders will be considered in detail, with an exploration of the natural history, available treatment options, and controversies regarding management. Current intervention criteria will be reviewed with respect to both open surgical repair and endovascular treatment. Our goal is to provide the healthcare professional with a better understanding of the pathophysiology of the various disease processes that involve the descending thoracic aorta and to review current outcomes and technical pitfalls associated with these therapies to facilitate strong, evidence-based decision making in the care of these patients. Treatment of descending TAD involves complex, exigent decision making in an era of evolving technology. Survival data for nonoperative …

In a small number of patients who undergo coronary artery bypass graft surgery (CABG), a hemodynamically significant aortic valve lesion requiring aortic valve replacement (AVR) develops as they grow older. In a limited number of studies in small patient groups, high mortality has been shown in patients undergoing AVR after CABG. We undertook this study to determine the mortality risk factors for patients who undergo AVR after CABG procedures. The outcome of 104 patients treated at our institution between January 1983 and December 1993 was retrospectively reviewed. The initial surgery was CABG in all patients. The patient population included 86 men (83%) and 18 women (17%); their mean age was 67 years. Overall, 70% of patients had congestive heart failure, and 96% had multivessel coronary artery disease. The diagnosis was aortic stenosis in 68% of patients, aortic insufficiency in 16%, and combined aortic stenosis and aortic insufficiency in 16%. Postoperative complications included worsening congestive heart failure (35%), perioperative myocardial infarction (13%), and bleeding (28%). The early mortality was 14%, and the late mortality was 17% (mean follow-up, 35 months). The risk factors for early mortality were number of diseased vessels (P = .028), renal failure (0.000), and prior myocardial infarction (P = .028). A perioperative predictor of early mortality was cardiopulmonary bypass time (P = .000). The risk factors for late mortality included preoperative diabetes mellitus (P = .007), postoperative acute respiratory distress syndrome (P = .011), and ventricular arrhythmias (P = .0001). The survival at 1, 5, and 10 years was 96%, 75%, and 49%, respectively. Risk factors were identified for early and late mortality in patients undergoing AVR after previous CABG. Although early morbidity and mortality were high, the longterm outcome of the survivors was favorable.

Endovascular Repair Versus Surgical Repair for Japanese Patients With Ruptured Thoracic and Abdominal Aortic Aneurysms: A Nationwide Study