Vascular Problems of the Pelvis

Regardless of the gender, the human pelvis represents a complex anatomic region shared by the organs of the gastrointestinal and genitourinary tracts and the reproductive system. All these structures are included in a rigid bone case which also harbors the intricate neurovascular network that crosses over the pelvic area in direction to the lower limbs. The adequate approach of the diseases arising in the pelvic vascular network is difficult requiring precise anatomical knowledge and often the collaboration of interdisciplinary teamwork. The present chapter describes in detail the pelvic vascular anatomy and also provides a full discussion of both the tumor-related and tumor-unrelated diseases affecting these vascular structures

Meta-analysis of individual-patient data from EVAR-1, DREAM, OVER and ACE trials comparing outcomes of endovascular or open repair for abdominal aortic aneurysm over 5 years

Item does not contain fulltextBACKGROUND: The erosion of the early mortality advantage of elective endovascular aneurysm repair (EVAR) compared with open repair of abdominal aortic aneurysm remains without a satisfactory explanation. METHODS: An individual-patient data meta-analysis of four multicentre randomized trials of EVAR versus open repair was conducted to a prespecified analysis plan, reporting on mortality, aneurysm-related mortality and reintervention. RESULTS: The analysis included 2783 patients, with 14 245 person-years of follow-up (median 5.5 years). Early (0-6 months after randomization) mortality was lower in the EVAR groups (46 of 1393 versus 73 of 1390 deaths; pooled hazard ratio 0.61, 95 per cent c.i. 0.42 to 0.89; P = 0.010), primarily because 30-day operative mortality was lower in the EVAR groups (16 deaths versus 40 for open repair; pooled odds ratio 0.40, 95 per cent c.i. 0.22 to 0.74). Later (within 3 years) the survival curves converged, remaining converged to 8 years. Beyond 3 years, aneurysm-related mortality was significantly higher in the EVAR groups (19 deaths versus 3 for open repair; pooled hazard ratio 5.16, 1.49 to 17.89; P = 0.010). Patients with moderate renal dysfunction or previous coronary artery disease had no early survival advantage under EVAR. Those with peripheral artery disease had lower mortality under open repair (39 deaths versus 62 for EVAR; P = 0.022) in the period from 6 months to 4 years after randomization. CONCLUSION: The early survival advantage in the EVAR group, and its subsequent erosion, were confirmed. Over 5 years, patients of marginal fitness had no early survival advantage from EVAR compared with open repair. Aneurysm-related mortality and patients with low ankle : brachial pressure index contributed to the erosion of the early survival advantage for the EVAR group. Trial registration numbers: EVAR-1, ISRCTN55703451; DREAM (Dutch Randomized Endovascular Aneurysm Management), NCT00421330; ACE (Anevrysme de l'aorte abdominale, Chirurgie versus Endoprothese), NCT00224718; OVER (Open Versus Endovascular Repair Trial for Abdominal Aortic Aneurysms), NCT00094575