Faculty Bibliography

Objective: Autogenous great saphenous vein (GSV) is considered the conduit of choice for lower extremity bypass (LEB). However, the optimal configuration has remained a source of debate. We compared the outcomes of patients who had undergone LEB using in situ and reversed configuration.
Method(s): The Vascular Quality Initiative database (January 2003 to February 2021) was queried for patients undergoing LEB with in situ and reversed GSV. Patient demographics, procedural detail, and in-hospital and follow-up outcomes were collected. The primary endpoint was primary patency. The second endpoints included freedom from major adverse limb events (MALE; defined as major lower extremity amputation and reintervention), limb salvage, and freedom from reintervention at 1 year. Multivariable models were created to determine the association between bypass configuration and outcomes of interest.
Result(s): Of the 8234 patients who had undergone LEB, in situ and reversed GSV was used in 3546 and 4688 patients, respectively. Patients with in situ bypass were older with higher rates of cardiopulmonary and renal comorbidities. The patients who had undergone reversed bypass were more likely to have undergone previous LEBs and endovascular interventions. The indication for LEB was similar between the in situ and reversed bypass cohorts. In situ bypass had been performed more frequently from the common femoral artery and to more distal targets (tibial or peroneal). Reversed bypass was associated with higher intraoperative blood loss and a longer operative time. Perioperatively, in situ bypass had resulted in greater rates of reintervention (13.2% vs 11.1%; P =.004) and surgical site infection (4.2% vs 3%; P =.003) and lower primary patency (93.5% vs 95%; P =.004). At 1 year, in situ bypass had a lower rate of MALE (22.6% vs 25.6), mainly driven by a lower rate of reintervention (19.4% vs 21.6%). The primary patency and limb salvage rates were not different. On multivariable analysis, in situ bypass was associated with lower primary patency loss (hazard ratio [HR], 0.9; 95% confidence interval [CI], 0.82-0.98), reintervention (HR, 0.88; 95% CI, 0.8-0.97), and MALE (HR, 0.89; 95% CI, 0.81-0.97) but did not affect the rate of limb salvage compared with reversed bypass.
Conclusion(s): Compared with those with reversed GSV, LEBs with in situ GSV confer improved primary patency and MALE at midterm. Our results have demonstrated that an in situ configuration might be a favorable option for appropriately selected patients with suitable anatomy.
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BACKGROUND:With the exponential increase in the use of endovascular techniques in the treatment of peripheral artery disease, our understanding of factors that affect intervention failures continues to grow. We sought to assess the outcomes of percutaneous transluminal angioplasty for isolated de novo superficial femoral artery (SFA) disease based on balloon diameter. METHODS:The Vascular Quality Initiative database was queried for patients undergoing percutaneous balloon angioplasty for isolated de novo atherosclerotic SFA disease. Based on the diameter of the angioplasty balloon as a surrogate measure of arterial diameter, patients were stratified into two groups: group 1, balloon diameter < 5 mm (354 patients) and group 2, balloon diameter ≥ 5 mm (1,550 patients). The primary patency and major adverse limb event (MALE) were estimated by the Kaplan-Meier method and compared with the log-rank test, based on vessel diameter. multivariable Cox regression analysis was used to determine factors associated with the primary patency. RESULTS:From January 2010 through December 2018, a total of 1,904 patients met criteria for analysis, with a mean follow-up of 13.3 ± 4.5 months. The mean balloon diameters were 3.92 ± 0.26 mm and 5.47 ± 0.55 mm in group 1 and 2, respectively (P<.001). The mean length of treatment and distribution of TASC lesions were not statistically different between the groups. Primary patency at 18 months was significantly lower in group 1, compared with group 2 (55% vs 67%; log-rank P<.001). The MALE rate was higher in group 1 than group 2 (33% vs 26%; log-rank P<.001). Among patients with claudication, there was no significant difference in the primary patency (61% vs 68%; log-rank P=.073) and MALE (27% vs 22%; log-rank P=.176) at 18 months between groups 1 and 2, respectively. However, in patients with CLTI, group 1 had significantly lower 18-month primary patency (47% vs 64%; log-rank P<.014) and higher MALE rates (41% vs 35%; log-rank P=.012) than group 2. Cox proportional hazard analysis confirmed that balloon diameter < 5 mm was independently associated with increased risks of primary patency loss (HR 1.35; 95% CI, 1.04-1.72; P=.021) and MALE (HR 1.29; 95% CI, 1-1.67; P=.048) at 18-months. CONCLUSIONS:In patients undergoing isolated SFA balloon angioplasty for CLTI, smaller SFA (< 5mm) was associated with worse primary patency and MALE. Using balloon size as a surrogate, our findings suggest that patients with a smaller SFA diameter appear to be at increased risk for treatment failure and warrant closer surveillance. Furthermore, these patients may also be considered for alternative approaches, including open revascularization.

Objective: Type II endoleaks (T2E), commonly identified after EVAR, are associated with late endograft failure and secondary rupture. Quantity and size of aortic aneurysm sac outflow vessels (AASOV), namely the inferior mesenteric, lumbar, and accessory renal arteries, have been implicated as known risk factors for persistent T2E. Given technical difficulties associated with post-EVAR embolization, prophylactic coil embolization of AASOV-related T2E has been advocated to prevent retrograde T2E; however, current evidence is limited. We sought to examine the effect of concomitant prophylactic AASOV coil embolization in patients undergoing EVAR.
Method(s): Patients 18 and older in the Society for Vascular Surgery Vascular Quality Initiative database who underwent elective EVAR for intact aneurysms between January 2009 and November 2020 were included. Patients with a history of prior aortic repair and those without available follow-up data were excluded. Patient demographics, operative characteristics, and outcomes were analyzed by group: EVAR with or without prophylactic AASOV embolization (emboEVAR). Primary outcomes of interest were rates of in-hospital postoperative complications, incidence of aneurysmal sac regression (>=5 mm), and rates of reintervention in follow-up.
Result(s): A total of 15,060 patients were included: 272 had emboEVAR and 14,788 had EVAR alone. There was no significant difference between groups in terms of age, comorbidities, or anatomic characteristics including mean maximum preoperative aortic diameter (5.5 vs 5.6 cm, P =.48) (Table I). emboEVAR was associated with significantly longer procedural times (148 vs 124 minutes, P <.0001), prolonged fluoroscopy (32 vs 23 minutes, P <.0001), increased contrast use (105 vs 91 mL, P <.0001), without significant reduction in T2E at completion (17.7% vs 16.3%, P =.54). Incidences of postoperative complications (3.7% vs 4.6%, P =.56), index hospitalization reintervention rates (0.7% vs 1.3%, P =.59), length of stay (1.8 vs 2 days, P =.75), and 30-day mortality (0% vs 0%, P = 1) were similar between groups. In mid-term follow-up (14.6 +/- 6.2 months), the emboEVAR group had a significant mean reduction in maximum aortic diameter (0.69 vs 0.54 cm, P =.006) with a higher proportion experiencing sac regression >=5 mm (53.5% vs 48.7%) and reintervention rates were similar between groups. On multivariate analysis, prophylactic AASOV (odds ratio: 1.34, confidence interval: 1.04-1.74, P =.024) was a significant independent predictor of sac regression (Table II).
Conclusion(s): Prophylactic AASOV embolization can be performed safely for patients with intact aortic aneurysms undergoing elective EVAR without significant associated perioperative morbidity or mortality. emboEVAR is associated with significant sac regression compared with EVAR alone in mid-term follow-up. This technique shows promise and future efforts should focus on elucidating the role of concomitant selective vs complete prophylactic AASOV embolization in patients undergoing EVAR. [Formula presented] [Formula presented]
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Objectives: In patients with carotid stenosis, both the severity of the stenosis as well as the plaque morphology influence the likelihood of future transient ischemic attack or stroke. In general, severely stenotic lesions are presumed to have a higher embolic potential than moderately stenotic lesions. Carotid intervention is indicated in patients with both moderate and severe stenosis with related cerebrovascular symptoms. However, the effect of the degree of carotid stenosis in symptomatic patients upon the outcome of carotid intervention has not been extensively studied.
Method(s): The Society for Vascular Surgery Quality Initiative database was queried for all patients undergoing transfemoral carotid stenting (CAS), carotid endarterectomy (CEA), and transcervical carotid stenting (TCAR) between 2003 and 2020. Patients undergoing interventions for symptomatic disease were included in the analysis. Patients were stratified into two cohorts based on the severity of stenosis-moderate (0%-69%) and severe (greater than or equal to 70%). Primary endpoints were perioperative neurologic events (strokes and transient ischemic attacks [TIAs]). Secondary endpoints were perioperative mortality and postoperative complications.
Result(s): Over 50,000 patients were included in the analysis: 5296 patients (8.9%) underwent TCAR, 7844 (13.3%) underwent CAS, and 45,853 (77.8%) underwent CEA for symptomatic carotid artery disease. In the TCAR and CEA cohorts, patients with moderate stenosis had a significantly higher rate of perioperative neurologic events than patients with severe stenosis (TCAR 4.3% vs 3.0%; P =.033; CEA 3.0% vs 2.3%; P <.001). In contrast, in patients undergoing CAS, there was no significant difference noted in the perioperative neurologic event rate (3.5% in moderate stenosis group vs 3.8% in severe stenosis group; P =.518). There were no differences in perioperative myocardial infarction or mortality (Table). On multivariable analysis, moderate stenosis was significantly and independently associated with an increased rate of neurologic events in the TCAR (odds ratio [OR], 0.833; 95% confidence interval, 0.693-1.000; P =.05), and CEA (odds ratio, 0.901; 95% confidence interval, 0.861-0.944; P <.001) cohorts.
Conclusion(s): Moderate carotid stenosis was associated with increased perioperative neurologic events in patients undergoing TCAR and CEA, but not CAS. Therefore, this effect was noted only in the cohorts that require direct open surgical manipulation of the cervical carotid artery (TCAR and CEA). Moderately stenotic lesions that become symptomatic likely have worse intrinsic plaque morphology than severely stenotic lesions, producing cerebrovascular symptoms at a lower degree of stenosis. The mechanism of such events warrants further evaluation with a particular focus on plaque morphology and brain physiology. [Formula presented]
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Objective: Data regarding the effect of bilateral internal iliac artery (IIA) occlusion during endovascular abdominal aortic aneurysm repair (EVAR) are conflicting, with reported varied risks of pelvic and gastrointestinal ischemia. The aim of our study was to report the perioperative and long-term outcomes of IIA occlusion with origin graft coverage in patients undergoing elective EVAR.
Method(s): Using the Vascular Quality Initiative database (2010-2020), we retrospectively identified patients who had undergone EVAR for infrarenal abdominal aortic aneurysms and aortoiliac aneurysms with or without IIA occlusion by graft coverage or coils. The patients were stratified into three groups according to IIA occlusion status (none, unilateral, bilateral). The baseline characteristics, procedural details, in-hospital outcomes, and overall survival at 5 years were reviewed. The primary outcomes were in-hospital mortality and complications. The secondary outcomes included 5-year mortality. Cox proportional hazards models were used to determine the predictive factors of perioperative and 2-year mortality.
Result(s): A total of 26,690 patients were identified (mean age, 73.5 years; 82% male) who had undergone elective EVAR with bifurcated endografts. Of the 26,690 patients, 2195 (8.2%) had undergone adjunctive unilateral IIA origin graft occlusion, 523 (2%) had undergone bilateral IIA origin graft occlusion, and 23,970 (89.8%) had not undergone any IIA graft occlusion. Perioperatively, no statistically significant differences were found in the incidence of death (0.4% vs 0.6% vs 0.4%; P =.2), gastrointestinal ischemia (0.1% vs 0.1% vs 0.2%; P =.888), unplanned reoperation (1.5% vs 1.8% vs 2.3%; P =.181), or cardiopulmonary complications (2.5% vs 2.8% vs 3.4%; P =.247) among those with no, unilateral, and bilateral IIA origin graft occlusion, respectively (Table). The Kaplan-Meier estimate demonstrated comparable overall survival at 5 years (none, 86.7%; unilateral, 85.2%; bilateral, 89.4%; P =.133; Fig). On multivariable analysis, the status of IIA origin graft coverage was not associated with increased perioperative mortality or complications.
Conclusion(s): EVAR with bilateral IIA interruption was associated with favorable perioperative outcomes with a low rate of major complications. At the time of EVAR, unilateral and bilateral IIA occlusion with a stent-graft did not appear to confer additional risks of perioperative complications and mortality. Our results showed the safety of bilateral IIA interruption in patients undergoing elective EVAR for abdominal aortic aneurysms and aortoiliac aneurysms. [Formula presented] [Formula presented]
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Objective: There is a paucity of data evaluating outcomes of lower extremity bypass (LEB) using suprainguinal inflow for infrainguinal vessels. The purpose of this study is to report outcomes after LEB originating from aortoiliac arteries to infrafemoral targets.
Method(s): The Vascular Quality Initiative database (2003-2020) was queried for patients undergoing LEB originating from the aortoiliac arteries and to the popliteal and tibial arteries. Patients were stratified into three cohorts based on outflow targets (above-knee popliteal, below-knee popliteal and tibial arteries). Perioperative and 1-year outcomes including primary patency, amputation-free survival, and major adverse limb events (MALEs) were compared, and the Cox proportional hazards model was used to estimate the independent prognostic factors of outcomes.
Result(s): Of 403 LEBs, 389 (96.5%) originated from the external iliac artery, whereas the remaining from the aorta and common iliac artery. A total of 116 (28.8%), 151 (27.5%), and 136 (43.7%) were to the above-knee popliteal, below-knee popliteal, and tibial arteries, respectively (Table). In total, 194 (48%) and 186 (46%) patients had prior ipsilateral LEB and percutaneous vascular interventions, respectively. Below-knee popliteal and tibial bypasses were performed more frequently in patients with chronic limb-threatening ischemia (70% and 70% vs 48%; P <.001). Vein conduit was more often used for tibial bypass than for above- and below-knee popliteal bypasses (46% vs 22% and 17%; P <.001). In the perioperative period, below-knee popliteal and tibial bypass patients had higher reoperation rates (17% and 14% vs 5%; P =.015) and lower primary patency (91% and 90% vs 96%; P =.044) than above-knee bypass patients. Perioperative pulmonary complication and mortality rates were similar among the cohorts. At 1 year, compared with above-knee popliteal bypasses, below-knee and tibial bypasses demonstrated lower primary patency (60.9% and 62.3% vs 83.3%; P <.001; Fig) and amputation-free survival (69.1% and 66.4% vs 79.4%; P =.0223), but freedom from MALEs were similar (87.2% and 82.8% vs 90.9%; P =.0585). On multivariable analysis, compared with above-knee popliteal bypasses, tibial bypasses were independently associated with increased loss of primary patency (hazard ratio, 1.9; 95% confidence interval, 1.03-3.51; P =.039), but with similar major ipsilateral amputation/death and MALEs.
Conclusion(s): Compared with those using historic infrainguinal inflow, LEBs with suprainguinal inflow appear to have accepTable rates of 1-year patency and limb salvage in patients at high risk of bypass failure. Tibial outflow target was independently associated with worse primary patency. [Formula presented] [Formula presented]
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Objective: Although beta-blocker (BB) use is routine for type B aortic dissections (TBADs), its effect in patients undergoing thoracic endovascular aortic repair (TEVAR) is unclear. Furthermore, the effect of BB use on the perioperative outcomes after TEVAR has not been evaluated. We evaluated the effect of BB use on the perioperative outcomes in patients with TBAD undergoing TEVAR.
Method(s): The Society for Vascular Surgery Vascular Quality Initiative database was queried for all patients who had undergone TEVAR for TBAD between September 2012 and February 2020. BB use was defined as the use of such medications for >=30 days preoperatively. Patients were dichotomized according to preoperative BB use (no-BB and BB cohorts). The patient characteristics, procedural details, and postoperative outcomes were compared. The primary endpoints were 30-day mortality and overall postoperative complications, including myocardial infarction, new dysrhythmia, congestive heart failure, access site complications, respiratory, cerebrovascular symptoms, and arm, leg, renal, spinal cord, and gastrointestinal ischemia requiring surgical intervention.
Result(s): Of 2283 patients undergoing TEVAR for TBAD, 1130 (49%) were receiving a BB preoperatively. The BB cohort was older with greater proportions of hypertension, coronary artery disease, congestive heart failure, diabetes, chronic kidney disease, and end-stage renal disease (Table I). Additionally, the BB cohort were more likely to be taking aspirin, a P2Y12 antagonist, a statin, or an ACE inhibitor, and/or receiving anticoagulation therapy preoperatively. The non-BB cohort had more nonelective, symptomatic, and acute dissections. The procedural details, including rates of open conversion and general anesthesia, estimated blood loss, transfusion requirements, and operative times were comparable. On univariate analysis, the BB cohort had a lower risk of overall postoperative complications (22% vs 33%; P <.001) and mortality (4.7% vs 7.7%; P =.003) compared with the non-BB cohort. On multivariable analysis, BB use was associated with a 22% reduction in the odds of postoperative complications (odds ratio, 0.78; 95% confidence interval, 0.62-0.99; P =.044) but did not influence mortality (odds ratio, 1.14; 95% confidence interval, 0.73-1.71; P =.562; Table II).
Conclusion(s): BB use was associated with a significant reduction in postoperative complications for patients undergoing TEVAR for TBAD. Therefore, BB use should be strongly encouraged for appropriately selected patients undergoing TEVAR. [Formula presented] [Formula presented]
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BACKGROUND:Autologous vein is considered the preferred conduit for lower extremity bypass. There is, however, limited literature regarding conduit choice for open popliteal artery aneurysm (PAA) repair. We sought to compare outcomes of PAA repair using vein versus prosthetic conduits. METHODS:The Vascular Quality Initiative database (2003-2019) was queried for patients with PAAs undergoing elective conventional revascularization originating from the superficial femoral and popliteal arteries. Conduits were categorized as vein or prosthetic. Primary outcomes were primary graft patency, freedom from major adverse limb event (MALE) and MALE-free survival at 2-years. Kaplan-Meier method with log-rank tests was used for estimation and comparison of patency. RESULTS:A total of 1,146 limbs in 1,065 patients underwent elective open revascularization for popliteal artery aneurysm. Vein was used in 921 limbs (80%), and prosthetic in 225 (20%). Patients in the prosthetic cohort had a shorter procedure time, were older, and had a higher prevalence of COPD. Postoperatively, prosthetic patients were more likely to be started and maintained on anticoagulation without increased incidence of hematoma. There was no significant difference in the rate of surgical site infection (2% vs. 2%; P = .946). There was an increased tendency toward more symptomatic patients in the vein cohort although not statistically significant (49% vein vs. 41% prosthetic; P = .096). On a mean follow-up of 13 ± 5 months, the incidence of MALE and MALE-free survival were comparable between the two groups. The 2-year primary and secondary patency rates were similar, 87% and 96% in the vein, and 91% and 95% in the prosthetic groups, respectively. At multivariable analysis, outflow bypass targets to the infrapopliteal arteries (HR 2.05; 95% confidence interval (CI), 1.16-3.65; P = .014) and symptomatic aneurysm (HR 1.81; 95% CI, 1.04-3.15; P = .037) were independently associated with loss of primary patency. Conduit type did not make a difference in MALE-free survival, or primary graft patency at 2-years. CONCLUSIONS:Our study demonstrates that conventional open PAA repair with prosthetic conduit yields results comparable to those with vein conduit with regard to primary and secondary patency and major adverse limb events at 2-years for targets to the popliteal artery. However, when the distal target was infrapopliteal, worse outcomes were observed with prosthetic conduit. Our results suggest that vein conduit should be preferentially used for infrapopliteal targets, while prosthetic conduit confers comparable outcomes in a subset of patients who do not have suitable autologous vein conduits.

INTRODUCTION/BACKGROUND:The natural history of penetrating aortic ulcers (PAU) and intramural hematomas (IMH) of the aorta is not well described. While repair is warranted for rupture, unremitting chest pain or growth, there is no established threshold for treating incidental findings. Thoracic endovascular aortic repair (TEVAR) offers an attractive approach in treating these pathologies, however, peri-procedural and post-operative outcomes are not well defined. METHODS:Patients 18 or older identified in the VQI database who underwent TEVAR for PAU and/or IMH between 1/2011-2/2020 were included. We identified 1042 patients, of whom 809 had available follow-up data. Patient demographics and comorbidities were analyzed to identify risk factors for major adverse events (MAE), as well as postoperative and late mortality. RESULTS:The cohort was 54.8% female and 69.9% former smokers with a mean age of 71.1 years. Comorbidities were prevalent with 57.8% classified ASA IV; 89.8% had hypertension, 28.3% chronic obstructive pulmonary disease (COPD), 17.9% coronary artery disease, and 12.2% congestive heart failure (CHF). Patients were predominately symptomatic (74%) and 44.5% underwent non-elective repair. MAE incidence was 17%. Independent predictors of MAE were history of CAD, non-Caucasian race, emergent procedural indication, ruptured presentation, and deployment of two or more endografts. In-hospital mortality was 4.3%. Seventy-three percent of index hospitalization mortalities were treatment-related. Of 809 patients with follow-up (mean 25.1 months±19 months), all-cause mortality was 10.6%. Predictors of late mortality in follow-up included age greater than 70 years, ruptured presentation, and history of COPD and ESRD. Subset analysis comparing symptomatic (74%) vs. asymptomatic (26%) patients demonstrated the former were frequently female (58.2% vs. 45.3%, p<.001) with a higher incidence of MAE (20.6% vs. 6.9%, p<.001), notably higher in-hospital reintervention rates (5.9% vs. 1.5%, p=.002) and mortality (5.6% vs. 0.7%, log-rank p=.015), and prolonged length of stay (6.9 vs. 3.7 days, p<.0001) despite similar procedural risks. In follow-up, late mortality was higher in the symptomatic cohort (12.2% vs. 6.5%, log-rank p=.025), with all treatment-related mortalities limited to the symptomatic group. CONCLUSIONS:We demonstrate significantly higher morbidity and mortality in symptomatic patients undergoing repair compared to asymptomatic patients, despite similar baseline characteristics. Asymptomatic patients treated with TEVAR had no treatment-related mortality in follow-up, with overall prognosis largely dependent on pre-existing comorbidities. These findings, in conjunction with growing evidence highlighting the risk of disease progression and attendant morbidity associated with these aortic entities, suggest a need for natural history studies and definitive guidelines on the elective repair of IMH and PAU.

OBJECTIVE:Endovascular abdominal aortic aneurysm repair (EVAR) is preferred to open surgical repair (OSR) for the treatment of abdominal aortic aneurysm (AAA) in high-risk patients. We sought to compare perioperative and long-term outcomes for EVAR in patients designated as unfit for OSR using a large national dataset. METHODS:The Vascular Quality Initiative database collected from 2013 to 2019 was queried for patients undergoing elective EVARs for AAA > 5cm. The patients were stratified into two cohorts based on the suitability for OSR (FIT vs. UNFIT). Primary outcomes included perioperative (in-hospital) major adverse events, perioperative mortality, and mortality at 1 and 5 years. Patient demographics and postoperative outcomes were analyzed to identify predictors of perioperative and long-term mortality. RESULTS:Of 16,183 EVARs, 1,782 patients were deemed unfit for OSR. The UNFIT cohort was more likely to be older and female, with higher proportions of HTN, CAD, CHF, COPD, and larger aneurysm diameter. Postoperatively, the UNFIT cohort was more likely to have cardiopulmonary complications (6.5% vs. 3%; P<.001), with higher perioperative mortality (1.7% vs. 0.6%; P<.001) and 1 and 5-year mortality (13% and 29% UNFIT vs. 5% and 14% FIT; P<.001). Subgroup analysis within the UNFIT cohort revealed those deemed unfit due to hostile abdomen had significantly lower 1 and 5-year mortality (6% and 20%) compared to those unfit due to cardiopulmonary compromise and frailty (14% and 30%; P=.451). Reintervention-free survival at 1 and 5-years was significantly higher in the FIT cohort (93% and 82%) as compared to the UNFIT cohort (85% and 68%; P<.001). Designation as unfit for OSR was an independent predictor of both perioperative (OR 1.59; 95% CI, 1.03-2.46; P=.038) and long-term mortality (HR 1.92; 95% CI, 1.69-2.17; P<.001). Advanced age (OR 2.91; 95% CI, 1.28-6.66; P=.011) was the strongest determinant of perioperative mortality while ESRD (HR 2.51; 95% CI, 1.78-3.55; P<.001) was the strongest predictor of long-term mortality. Statin (HR 0.77; 95% CI, 0.69-0.87; P<.001) and ACE inhibitor (HR 0.83; 95% CI, 0.75-0.93; P<.001) were protective of long-term mortality. CONCLUSION/CONCLUSIONS:Despite low perioperative mortality, long-term mortality of those designated by the operating surgeons as unfit for OSR was rather high in patients undergoing elective EVARs, likely due to the competing risk of death from their medical frailty. Unfit designation due to hostile abdomen did not confer any additional risks after EVAR. Judicious estimation of the patient's life expectancy is essential when considering treatment options in this subset of patients deemed unfit for OSR.