Hospital cost of endovascular versus open repair of abdominal aortic aneurysms: a multicenter study

Long-term outcomes after endovascular abdominal aortic aneurysm repair: the first decade

OBJECTIVE

The proper role of endovascular abdominal aortic aneurysm repair (EVAR) remains controversial, largely due to uncertain late results. We reviewed a 12-year experience with EVAR to document late outcomes.

METHODS

During the interval January 7, 1994 through December 31, 2005, 873 patients underwent EVAR utilizing 10 different stent graft devices. Primary outcomes examined included operative mortality, aneurysm rupture, aneurysm-related mortality, open surgical conversion, and late survival rates. The incidence of endoleak, migration, aneurysm enlargement, and graft patency was also determined. Finally, the need for reintervention and success of such secondary procedures were evaluated. Kaplan-Meier and multivariate methodology were used for analysis.

RESULTS

Mean patient age was 75.7 years (range, 49-99 years); 81.4% were male. Mean follow-up was 27 months; 39.3% of patients had 2 or more major comorbidities, and 19.5% would be categorized as unfit for open repair. On an intent-to-treat basis, device deployment was successful in 99.3%. Thirty-day mortality was 1.8%. By Kaplan-Meier analysis, freedom from AAA rupture was 97.6% at 5 years and 94% at 9 years. Significant risk factors for late AAA rupture included female gender (odds ratio OR, 6.9; P = 0.004) and device-related endoleak (OR, 16.06; P = 0.009). Aneurysm-related death was avoided in 96.1% of patients, with the need for any reintervention (OR, 5.7 P = 0.006), family history of aneurysmal disease (OR, 9.5; P = 0.075), and renal insufficiency (OR, 7.1; P = 0.003) among its most important predictors. 87 (10%) patients required reintervention, with 92% of such procedures being catheter-based and a success rate of 84%. Significant predictors of reintervention included use of first-generation devices (OR, 1.2; P < 0.01) and late onset endoleak (OR, 64; P < 0.001). Current generation stent grafts correlated with significantly improved outcomes. Cumulative freedom from conversion to open repair was 93.3% at 5 through 9 years, with the need for prior reintervention (OR, 16.7; P = 0.001) its most important predictor. Cumulative survival was 52% at 5 years.

CONCLUSIONS

EVAR using contemporary devices is a safe, effective, and durable method to prevent AAA rupture and aneurysm-related death. Assuming suitable AAA anatomy, these data justify a broad application of EVAR across a wide spectrum of patients.

Randomized EVAR Trials and Advent of Level I Evidence: A Paradigm Shift in Management of Large Abdominal Aortic Aneurysms?

The recent endovascular aneurysm repair (EVAR) 1 and 2 and Dutch Randomized Endovascular Aneurysm Management (DREAM) trials addressed management of abdominal aortic aneurysms (AAAs) larger than 5.5 cm in diameter. The DREAM and EVAR 1 trials randomized patients appropriate for open repair between endovascular repair (EVAR) and open repair (OR), and the EVAR 2 trial randomized patients unfit for OR between EVAR and conservative nonoperative management (No Rx). The EVAR 1 trial showed a 3% lower initial mortality for EVAR, with a persistent reduction in aneurysm-related death at 4 years. Improvement in overall late survival was not demonstrated. Similarly, the DREAM trial observed an initial mortality advantage for EVAR, but overall 1-year survival was equivalent in both groups. Both trials found significantly higher complication and intervention rates and higher hospital costs with EVAR, and by 1 year a quality of life (QOL) benefit was not evident. The EVAR 2 trial did not demonstrate a survival advantage of EVAR with respect to nonoperative management, while noting that EVAR was associated with greater likelihood of treatment complications, subsequent interventions, and threefold higher costs. Both EVAR trials were limited by long delays between randomization and treatment. Moreover, 27% of patients in EVAR 2 crossed over from nonoperative to endovascular repair, and these patients had a lower procedure mortality from EVAR than those originally assigned to it (2% v 9%). These 47 cases, and the exclusion of 14 patients dying while waiting for EVAR, appears to confer a survival advantage to those receiving EVAR over those receiving no treatment in a post-hoc analysis, but per-protocol analysis of the EVAR 2 trial data performed by the EVAR investigators did not show a significant difference in either all-cause or aneurysm-related mortality. Thus, outcomes of the EVAR 2 trial have not settled the choice between EVAR and no treatment in this scenario to everyone's satisfaction. In patients with large AAAs who are fit for OR, EVAR offers an initial mortality advantage over OR, with a persistent reduction in AAA-related death at 4 years. However, EVAR offers no overall survival benefit, is more costly, and requires more interventions and indefinite surveillance with only a brief QOL benefit. It may or may not offer a mortality benefit over nonoperative management in patients with large AAAs who are unfit for open repair, but the statistical significance of this comparison is inconclusive.

Follow-up costs increase the cost disparity between endovascular and open abdominal aortic aneurysm repair

OBJECTIVE

This study compared the hospital and follow-up costs of patients who have undergone endovascular (EVAR) or open (OR) elective abdominal aortic aneurysm repair.

METHODS

The records of 195 patients (EVAR, n = 55; OR, n = 140) who underwent elective aortic aneurysm repair between 1995 and 2004 were reviewed. Primary costing data were analyzed for 54 EVAR and 135 OR patients. Hospital costs were divided into preoperative, operative, and postoperative costs. Follow-up costs for EVAR patients were recorded, with a median follow-up time of 12 months.

RESULTS

Mean preoperative costs were slightly higher in the EVAR group (AU $961/US $733 vs AU $869/US $663; not significant). Operative costs were significantly higher in the EVAR group (AU $16,124/US $12,297 vs AU $6077/US $4635; P < .001); this was entirely due to the increased cost of the endograft (AU $10,181/US $7,765 for EVAR vs AU $476/US $363 for OR). Postoperative costs were significantly reduced in the EVAR group (AU $4719/US $3599 vs AU $11,491/US $8,764; P < .001). Total hospital costs were significantly greater in the EVAR group (AU $21,804/US $16,631 vs AU $18,437/US $14,063; P < .001). The increase in total hospital costs was due to a significant difference in graft costs, which was not offset by reduced postoperative costs. The average follow-up cost per year after EVAR was AU $1316/US $999. At 1 year of follow-up, EVAR remained significantly more expensive than OR (AU $23,120/US $17,640 vs AU $18,510/US $14,122; P < .001); this cost discrepancy increased with a longer follow-up.

CONCLUSIONS

EVAR results in significantly greater hospital costs compared with OR, despite reduced hospital and intensive care unit stays. The inclusion of follow-up costs further increases the cost disparity between EVAR and OR. Because EVAR requires lifelong surveillance and has a high rate of reintervention, follow-up costs must be included in any cost comparison of EVAR and OR. The economic cost, as well as the efficacy, of new technologies such as EVAR must be addressed before their widespread use is advocated.

Abdominal aortic aneurysm screening: recommendations and controversies

Extensive level one evidence supports routine abdominal aortic aneurysm (AAA) screening in men aged 65 to 75 years, because AAAs are highly prevalent in this population. Physical examination is an insensitive means of detection. Ruptured AAAs are costly with respect to quality adjusted life years (QALY) lost and medical expenses. Large scale, randomized trials have demonstrated that AAA screening reduces all AAA-related mortality in the screened population and is cost-effective in mid-term follow-up. AAA screening by ultrasound has many advantages over other accepted medical screening programs in its simplicity in structure and the availability of an inexpensive, portable, and reliable means of screening. Additionally, AAA screening almost entirely avoids the negative consequences associated with other screening programs, including the adverse psychological effects and medical costs associated with false-positive examination results. There are subgroups of at-risk women who might benefit from AAA screening, and this issue should be further studied.

Endovascular aneurysm repair versus open repair in patients with abdominal aortic aneurysm (EVAR trial 1): randomised controlled trial

BACKGROUND

Although endovascular aneurysm repair (EVAR) has a lower 30-day operative mortality than open repair, the long-term results of EVAR are uncertain. We instigated EVAR trial 1 to compare these two treatments in terms of mortality, durability, health-related quality of life (HRQL), and costs for patients with large abdominal aortic aneurysm (AAA).

METHODS

We did a randomised controlled trial of 1082 patients aged 60 years or older who had aneurysms of at least 5.5 cm in diameter and who had been referred to one of 34 hospitals proficient in the EVAR technique. We assigned patients who were anatomically suitable for EVAR and fit for an open repair to EVAR (n=543) or open repair (n=539). Our primary endpoint was all-cause mortality, with secondary endpoints of aneurysm related mortality, HRQL, postoperative complications, and hospital costs. Analyses were by intention to treat.

FINDINGS

94% (1017 of 1082) of patients complied with their allocated treatment and 209 died by the end of follow-up on Dec 31, 2004 (53 of aneurysm-related causes). 4 years after randomisation, all-cause mortality was similar in the two groups (about 28%; hazard ratio 0.90, 95% CI 0.69-1.18, p=0.46), although there was a persistent reduction in aneurysm-related deaths in the EVAR group (4%vs 7%; 0.55, 0.31-0.96, p=0.04). The proportion of patients with postoperative complications within 4 years of randomisation was 41% in the EVAR group and 9% in the open repair group (4.9, 3.5-6.8, p<0.0001). After 12 months there was negligible difference in HRQL between the two groups. The mean hospital costs per patient up to 4 years were UK pound sterling 13,257 for the EVAR group versus pound sterling 9946 for the open repair group (mean difference pound sterling 3311, SE 690).

INTERPRETATION

Compared with open repair, EVAR offers no advantage with respect to all-cause mortality and HRQL, is more expensive, and leads to a greater number of complications and reinterventions. However, it does result in a 3% better aneurysm-related survival. The continuing need for interventions mandates ongoing surveillance and longer follow-up of EVAR for detailed cost-effectiveness assessment.

Management of Abdominal Aortic Aneurysms

Abdominal aortic aneurysms (AAAs) are a lethal disease. Ultrasound is the modality of choice for screening patients for AAAs. It is reasonable to screen patients over age 60, particularly men, women with cardiovascular risk factors, smokers, and patients with a family history of AAAs. Patients with small (< 5.5 cm) AAAs should be followed with serial ultrasound. Medical management should focus on treating comorbidities, particularly those that put patients at risk for other cardiovascular diseases. Smoking cessation is mandatory in these patients. Patients with large or symptomatic AAAs should be evaluated for surgery; this includes careful imaging of the abdomen, aggressive treatment of comorbidities, and perioperative beta blockade. Endovascular repair has lower short-term morbidity compared with conventional open repair. Trials assessing long-term results are in progress. Basic science and translational research focusing on the underlying pathogenesis of AAAs will likely pave the way for medical therapies in the future.

Endovascular abdominal aortic aneurysm repair is more profitable than open repair based on contribution margin per day

BACKGROUND

Earlier studies have reported that endovascular abdominal aortic aneurysm (EAAA) repair yields lower total profit margins than open AAA (OAAA) repair. This study compared EAAA versus OAAA based on contribution margin per day, which may better measure profitability of new clinical technologies. Contribution margin equals revenue less variable direct costs (VDCs). VDCs capture incremental resources tied directly to individual patients' activity (eg, invoice price of endograft device, nursing labor). Overhead costs factor into total margin, but not contribution margin.

METHODS

The University of Michigan Health System's cost accounting system was used to extract fiscal year 2002-2003 information on revenue, total margin, contribution margin, and duration of stay for Medicare patients with principal diagnosis of AAA (ICD-9 code 441.4).

RESULTS

OAAA had revenues of $37,137 per case versus $28,960 for EAAA, similar VDCs per case, and thus higher contribution margin per case ($24,404 for OAAA vs $13,911 for EAAA, P < .001). However, OAAA had significantly longer mean duration of stay per case (10.2 days vs 2.2 days, P < .001). Therefore, mean contribution margin per day was $2948 for OAAA, but $8569 for EAAA ( P < .001).

CONCLUSIONS

On the basis of contribution margin per day, EAAA repair dominates OAAA repair. The shorter duration of stay with EAAA allows higher throughput, fuller overhead amortization, better use of scarce inpatient beds, and higher health system profits. Surgeons must understand overhead allocation to devices, especially when new technologies cut duration of stay markedly.

Midterm Survival After Endovascular Versus Open Repair of Infrarenal Aortic Aneurysms

PURPOSE

To report the midterm survival after endovascular repair (ER) of infrarenal aortic aneurysms and to compare the outcomes to contemporaneous patients treated with open repair (OR).

METHODS

Between January 1995 and December 2001, 498 patients were treated for abdominal aortic aneurysm: 289 (52%) underwent OR and 209 (48%) underwent ER at a single center. Preoperative risk factors were graded according to the SVS/AAVS risk stratification. A computerized database was used to record demographic, clinical, and follow-up data.

RESULTS

Significant benefits (p<0.0001) were observed in the ER group in terms of mean procedural time (163+/-66 versus 132+/-61 minutes), mean blood loss (1268+/-923 versus 122.5+/-284 mL), and mean hospital length of stay (16.24+/-13.3 versus 9.3+/-11.6 days). The perioperative mortality for OR and ER patients were, respectively, 5.1% and 1.5% (p=0.04). The mean follow-up was 40 months in the OR group (range 0-85) and 19 months in the ER group (range 2-80). Contact was lost with 31 (6%) patients during the study. No overall survival advantage was observed for OR over ER, and comparison of OR and ER according the risk classifications did not yield any significant differences. No patients died of aneurysm rupture, but 7 ER patients had to be converted to open surgery. The cumulative freedoms from reinterventions at 4 years for the OR and ER groups, respectively, were 87% and 63% (p=0.001). Patients treated by OR had better clinical success (p=0.001). Patients in the ER group without iliac artery aneurysm showed a significant improvement (p=0.035) over patients with aneurysmal iliac arteries.

CONCLUSIONS

Over the 7 years of this study, ER realized its goal: prevention of aneurysm rupture. Despite a greater number of reinterventions for ER patients, no overall survival difference was observed.

Endovascular treatment of abdominal aortic aneurysms

BACKGROUND

Endovascular treatment of abdominal aortic aneurysms is a rapidly evolving technique that has gained broad acceptance in the treatment of patients with abdominal aortic aneurysms.

METHODS

A review of the English literature was done to determine the short- and long-term outcomes of endovascular repair of abdominal aortic aneurysms. Reports of complications such as endoleak, graft migration, graft limb occlusion, aneurysm rupture, and aneurysm enlargement were evaluated.

RESULTS

Short-term results of endovascular repair of abdominal aortic aneurysms are excellent. The necessity for open conversions is less than 5%. The cumulative risk of aneurysm rupture is approximately 1% per year. The coverall incidence of graft limb occlusion was 2.8% in the follow-up period. The cumulative risk for a secondary procedure was 12% at 1 year, 24% at 2 years, and 35% at 3 years. Moderate and severe neck angulation was associated with an increased incidence of adverse events in the follow-up period. Endografts have the potential to become infected and develop aortoduodenal fistula. The treatment of ruptured aneurysms with endovascular grafts has been successful and a technique that is increasingly used.

CONCLUSION

Endovascular treatment of abdominal aortic aneurysm is an effective technique with excellent short-term results. The long-term results remain to be determined. Ongoing surveillance is necessary to avoid late complications of aneurysm rupture.

Surveillance after Endovascular Aneurysm Repair: Diagnostics, Complications, and Associated Costs

The purpose of this study is to describe the diagnostic tests used, the complications that occurred the reinterventions performed, and the costs incurred after endovascular aneurysm repair. Retrospective review was performed of 77 consecutive individuals in whom endovascular aortic grafts had been successfully deployed. The series represents a single institution's experience with prospective application of a surveillance program using high-resolution CT scanning. Follow-up was available for all individuals. Mean interval of follow-up was 19.9 months (range 1-72 months), yielding a cumulative follow-up of 1540 months. There were no cases of aneurysm rupture. A total of 315 CT scans were performed during follow-up. On the basis of predetermined criteria, 28 interventions were performed in 21 patients. Indications for intervention included change in aneurysm sac volume (21 procedures), limb ischemia (5 procedures), and infection (2 procedures). Seven individuals were converted to open repair an average of 28.5 months after graft implantation (range 4-69 months). Twenty-one additional procedures were performed in 15 individuals after an average of 14.8 months (range 1-63 months). Cumulative risk of intervention and overall costs were estimated as a function time from implantation. Estimated costs at one and five years were 3631 dollars and 9729 dollars. The cumulative risk of intervention at one year was 7.2%. The frequency and cost of post-implantation procedures after endovascular aortic intervention are substantial. As longer follow-up becomes available, continued postoperative expenses may cancel out the already marginal cost STET benefits of EVAR benefits of EVAR.

The UK Endovascular Aneurysm Repair (EVAR) Trials: Design, Methodology and Progress

OBJECTIVES

The endovascular aneurysm repair (EVAR) trials aim to assess the efficacy of EVAR in the treatment of AAA in terms of mortality, quality of life, durability and cost-effectiveness.

DESIGN

Male and female patients aged at least 60 years with an AAA diameter measuring at least 5.5 cm on a computed tomography (CT) scan are assessed for anatomical suitability for EVAR. Suitable patients are offered entry either into EVAR Trial 1 if they are considered fit for conventional open repair or EVAR Trial 2 if they are considered unfit. EVAR 1 randomly allocates patients to EVAR or open repair and EVAR 2 randomly allocates patients to EVAR with best medical treatment or best medical treatment alone. Target recruitment for EVAR Trials 1 and 2 is 900 and 280 patients, respectively.

PROGRESS

Recruitment began in September 1999 and there are currently 40 UK centres participating in the trials. Monthly targets are being exceeded in EVAR Trial 1 with 1037 patients randomised by October 2003. EVAR Trial 2 is also meeting monthly targets with a total of 319 patients randomised. When recruitment closes in December 2003 patients will need to be followed for at least 1 year from their operation. Publication of full results for both trials is expected in mid 2005.

Perioperative outcomes after open and endovascular repair of intact abdominal aortic aneurysms in the united states during 2001

OBJECTIVE

Small patient numbers, mixed data from clinical trials, and longitudinal series representing institutional learning curves have characterized previous studies of early outcomes after endovascular abdominal aortic aneurysm (AAA) repair. We compared the perioperative outcomes of endovascular and open surgical AAA repair in an unselected sample of patients in a single calendar year using a national administrative database.

METHODS

The 2001 National Inpatient Sample database was retrospectively reviewed. This database represents 20% of all-payer stratified sample of non-federal US hospitals. Patients older than 49 years were identified by primary diagnostic codes (International Classification of Disease, ninth revision [ICD-9], 441.4, intact, nonruptured AAA) and procedure codes (ICD-9 38.44 for open, 39.71 for endovascular repair). Patient demographic data (age, sex), comorbid conditions (ICD-9 coded), inpatient complications (ICD-9 coded), length of stay, final discharge disposition (home vs institution vs death), and hospital charges were examined with univariate and multivariate analyses.

RESULTS

In calendar year 2001, 7172 patients underwent either open (64%) or endovascular (36%) repair of intact, nonruptured AAAs. Despite comparable rates of preoperative comorbid conditions and a greater proportion of octogenarians (23% vs 16%%; P =.0001), morbidity (18% vs 29%; P =.0001) and mortality (1.3% vs 3.8%; P =.0001) were significantly lower for endovascular repair than for open repair. The median length of stay (2 vs 7 days; P =.0001) and the rate of discharge to an institutional facility versus home (6% vs 14%; P =.0001) were also much lower in the endovascular group than in the open repair group. At multivariate analysis, open AAA repair and age older than 80 years were strong independent predictors (P =.0001 for all) for death (open repair: odds ratio [OR], 3.3; 95% confidence interval [CI], 2.3-4.9; age: OR, 14.2; 95% CI, 3.5-58.1), complications (open repair: OR, 1.9; 95% CI, 1.7-2.1; age: OR, 1.9; 95% CI, 1.5-2.5), and not being discharged to home (open repair: OR, 3.4; 95% CI, 2.9-4.1; age: OR, 12.0; 95% CI, 7.0-20.4). Mean hospital charges were significantly greater (difference, $3337; P =.0009) for endovascular repair than for open repair. Extrapolated to the total number of endovascular AAA repairs performed during the single 2001 calendar year, this resulted in a staggering $50.3 million in additional hospital charges.

CONCLUSIONS

Endovascular repair of intact AAAs results in a significantly lower number of complications and deaths, shorter hospital stay, and improved likelihood of discharge to home, even in older patients, when compared with open surgical repair. These impressive gains in clinical outcome, however, are achieved at similarly impressive increases in health care costs.

Type II endoleak after endovascular abdominal aortic aneurysm repair: a conservative approach with selective intervention is safe and cost-effective

OBJECTIVES

The conservative versus therapeutic approach to type II endoleak after endovascular repair of abdominal aortic aneurysm (EVAR) has been controversial. The purpose of this study was to evaluate the safety and cost-effectiveness of the conservative approach of embolizing type II endoleak only when persistent for more than 6 months and associated with aneurysm sac growth of 5 mm or more.

METHODS

Data for 486 consecutive patients who underwent EVAR were analyzed for incidence and outcome of type II endoleaks. Spiral computed tomography (CT) scans were reviewed, and patient outcome was evaluated at either office visit or telephone contact. Patients with new or late-appearing type II endoleak were evaluated with spiral CT at 6-month intervals to evaluate both persistence of the endoleak and size of the aneurysm sac. Persistent (>or=6 months) type II endoleak and aneurysm sac growth of 5 mm or greater were treated with either translumbar glue or coil embolization of the lumbar source, or transarterial coil embolization of the inferior mesenteric artery.

RESULTS

Type II endoleaks were detected in 90 (18.5%) patients. With a mean follow-up of 21.7 +/- 16 months, only 35 (7.2%) patients had type II endoleak that persisted for 6 months or longer. Aneurysm sac enlargement was noted in 5 patients, representing 1% of the total series. All 5 patients underwent successful translumbar sac embolization (n = 4) or transarterial inferior mesenteric artery embolization (n = 4) at a mean follow-up of 18.2 +/- 8.0 months, with no recurrence or aneurysm sac growth. No patient with treated or untreated type II endoleak has had rupture of the aneurysm. The mean global cost for treatment of persistent type II endoleak associated with aneurysm sac growth was US dollars 6695.50 (hospital cost plus physician reimbursement). Treatment in the 30 patients with persistent type II endoleak but no aneurysm sac growth would have represented an additional cost of US dollars 200000 or more. The presence or absence of a type II endoleak did not affect survival (78% vs 73%) at 48 months.

CONCLUSIONS

Selective intervention to treat type II endoleak that persists for 6 months and is associated with aneurysm enlargement seems to be both safe and cost-effective. Longer follow-up will determine whether this conservative approach to management of type II endoleak is the standard of care.

A statewide experience with endovascular abdominal aortic aneurysm repair: Rapid diffusion with excellent early results

OBJECTIVE

The purpose of this study was to compare survival and outcomes of endovascular versus open repair of abdominal aortic aneurysms (AAAs) in New York State (NYS).

METHODS

We used the NYS discharge dataset Statewide Planning and Research Cooperative System (SPARCS) to analyze the outcomes of elective admission for nonruptured (International Classification of Diseases-9th revision [ICD-9] 441.4) open aneurysm repair (38.44) and endovascular aneurysm repair (39.71) during the years 2000-2002. The ICD-9 code for endovascular repair was introduced in late 2000, thus capturing 3 months of empiric data for 2000.

RESULTS

There has been a significant increase in the number of AAA procedures performed in NYS (comparing before and after 2000: average, 1419 vs 1701; P =.0001), temporally coinciding with the implementation of training programs after US Food and Drug Administration approval of endovascular grafts and the new payment code. From 2000 to 2002 the number of NYS hospitals performing endovascular repairs increased from 24 to 60. By 2002 there were more endovascular repairs being performed than open repairs (871 vs 783). The target population for these surgical interventions showed interesting differences. In 2002, women had a 43% chance of receiving an endograft, whereas men had a 55% probability. The use of endovascular repair over the observation period was relatively constant in patients younger than 65 years. In patients older than 65 years, and especially those older than 75 years, endovascular use increased substantially, so that by 2002 older patients were more likely to undergo endovascular repair than open repair. Patients who underwent endovascular repair had significantly more hypertension, coronary artery disease, diabetes, and hyperlipidemia than did patients who underwent open repair. Yet the mean length of stay for endovascular procedures was approximately 3.6 days, and for open procedures was about 10.3 days, across all 3 years (P = <.0001). Moreover, patients who underwent endovascular repair had statistically fewer postoperative complications and significantly lower mortality. In-hospital mortality in 2001 was 3.55% for open repair and 1.14% for endovascular repair (P =.0018), and in 2002 these rates were 4.21% versus 0.8% (P <.0001), respectively.

CONCLUSION

This dataset suggests that endovascular AAA repairs are being performed in a patient population with a higher frequency of comorbidities. However, endovascular repairs still are associated with significantly lower in-hospital mortality, fewer postoperative complications, and a dramatically shorter length of stay. These results suggest that, despite the rapid diffusion of this new technique, early perioperative outcomes may be superior to those with conventional open repair. However, prospective clinical studies are needed to confirm these insights, and such studies may require the infrastructure of consortia of hospitals or society-based registries.

Abdominal aortic aneurysms: elective endovascular repair versus conventional surgery--evaluation with evidence-based medicine techniques

PURPOSE

To use evidence-based techniques to compare elective open surgical repair of abdominal aortic aneurysms with endovascular repair by means of stent placement.

MATERIALS AND METHODS

A focused clinical question formed the basis of a literature search. Evidence-based criteria were used to appraise and assign a "level of evidence" to retrieved articles. The following data were determined from the best studies: systemic, local, and/or vascular complications; graft failure rates; blood loss; mortality; length of intensive care and/or hospital stay; mid- and long-term outcomes; cost of endovascular repair versus that of surgery; and eligibility for endovascular repair. Absolute risk reductions and/or increases and numbers needed to treat or harm were calculated.

RESULTS

The best current evidence came from 22 studies, which showed that there is slight, if any, difference between mortality rates of endovascular repair and surgery. Hospital and/or intensive care stay is shorter, blood loss less, and systemic complications fewer (numbers needed to treat, two to 12) with endovascular repair. Some authors reported a significant increase in local and/or vascular complications with endovascular repair (numbers needed to harm, two to six). Graft failure is significantly more common with endovascular repair (numbers needed to harm, four), and substantive adjunctive interventions are needed. Endovascular repair is more expensive than surgery.

CONCLUSION

Elective endovascular repair has short-term benefits compared with surgery. There is slight, if any, difference in mortality. Endovascular repair costs more than surgery. At follow-up, surgical grafts performed better.

Hospital costs for endovascular and open repair of abdominal aortic aneurysm

BACKGROUND

To evaluate hospital costs and reimbursement for open (OAAA) and endovascular (EVAAA) repair of abdominal aortic aneurysm.

STUDY DESIGN

Review of all patients who underwent OAAA or EVAAA in two teaching hospitals during the period January 1, 2000, to December 31, 2000, was completed for the following: demographics, Diagnosis Related Group (DRG), resource use, length of stay, hospital costs, and reimbursement data.

RESULTS

There were 130 abdominal aortic aneurysm procedures performed. Fifty-seven (44%) OAAA were completed; EVAAA was attempted in 73 (56%). Seventy EVAAA patients (96%) had endografts placed, and three (4%) required conversion to open repair. Significant differences were noted between OAAA and EVAAA in operative time (311.7 +/- 107.5 minutes versus 263.4 +/- 110.8 minutes, respectively, p = 0.02), ICU admission and length of stay (100%, 5.0 +/- 6.1 days versus 29%, 1.4 +/- 7.1 days, respectively, p = 0.003), and hospital length of stay (12.6 +/- 14.8 days versus 4.9 +/- 13.4 days, respectively, p = 0.002). Total costs were $17,539.00 for EVAAA and $9,042.00 for OAAA. EVAAA was profitable ($3,072.00) for Medicare DRG 110 classification, but significant loss occurred with DRG 111 ($5,065.00). Contract renegotiation with private payers (to cover graft costs) was necessary to avoid substantial per- patient loss ($12,108.00). Overall net per-patient profit for EVAAA was $737.00.

CONCLUSIONS

Endovascular abdominal aortic aneurysm repair is significantly more expensive than open repair, with the major portion attributed to graft cost. Although ICU use and total length of stay decreased with EVAAA, overall costs were not substantially reduced. Hospitals must develop new financial strategies and improve the efficiency of their infrastructures in order to offer EVAAA.

Mortality, morbidity, and costs of ruptured and elective abdominal aortic aneurysm repairs in Nova Scotia, Canada

Ruptured abdominal aortic aneurysms (RAAA) have a 78-94% mortality rate. If cost-effectiveness of screening programs for abdominal aortic aneurysms (AAA) are to be assessed, direct costs for RAAA repairs and elective AAA (EAAA) repairs are required. This study reports mortality, morbidity, and direct costs for RAAA and EAAA repairs in Nova Scotia in 1997-1998 and also compares Nova Scotia and U.S. costs. We performed a retrospective study of 41 consecutive RAAA and 48 randomly selected EAAA patients. Average total costs for RAAA repair were significantly greater than those for EAAA repair (direct costs: $15,854 vs. $9673; direct plus overhead costs: $18,899 vs. $12,324 [pricing in 1998 Canadian dollars]). Intensive care unit length of stay and blood product usage were the most substantial direct cost differentials ($3593 and $2106). Direct cost for preoperative testing and surveillance was greater in the EAAA group ($839 vs. $33). Estimates of U.S. in-hospital RAAA and EAAA repair costs are more than 1.5 times Nova Scotia costs. Direct in-hospital RAAA repair costs are $6181 more than EAAA repair costs. These in-hospital cost data are key cost elements required to assess the cost-effectiveness of various screening strategies for earlier detection and monitoring of AAA within high-risk populations in Canada. Further studies are required to estimate cost per quality-adjusted-life-year gained for various AAA screening and monitoring strategies in Canada.

The principles of cost-effectiveness analysis and their application

The current healthcare environment requires the evaluation of both the costs and benefits of alternative interventions for a given clinical problem. Given the increased interest in the economic evaluation of healthcare interventions, this article briefly defines various forms of economic evaluations and describes some useful steps for conducting appraisals of cost-effectiveness analyses. Studies of competing methods of treatment of abdominal aortic aneurysms greater than 5 cm are used as a clinical example of interest to the readers of this Journal. Rather than actually conducting such an analysis with existing data, we describe the principles for conducting or reviewing an economic analysis with factitious data.

Mid-term results of patients undergoing endovascular aortic aneurysm repair

BACKGROUND

The utilization of endovascular aneurysm repair (EAR) is increasing significantly; however, few papers have outlined mid-term outcomes.

METHODS

Patients undergoing EAR with an AneuRx endograft between September 1997 and May 2001 were evaluated. Mean follow-up was 20.7 +/- 11.9 (SD) months.

RESULTS

In all, 101 EAR devices were successfully deployed in 105 attempts. Four open conversions (2 acute, 2 delayed) were performed for complications of EAR. Technical, clinical, and 1 to 3 year continuing success rates were 75%, 73%, and 78% to 83%. When divided by the median date, significantly fewer patients in the later group required secondary procedures compared with the early group. Vascular insufficiency occurred in 12 patients; 11 were treated with a secondary procedure. For 9 type I and 9 type II persistent endoleaks, secondary procedures were attempted and successful in 10 patients. Of successful EAR deployments, including secondary interventions, 85% demonstrated no persistent leak, rupture, increase in aneurysm size, or migration at most recent follow-up.

CONCLUSIONS

EAR is successful in selected individuals; however, continuing follow-up is of paramount importance.

Initial results of endovascular repair of abdominal aortic aneurysms with a self-expanding stent-graft

PURPOSE

This study was performed to evaluate the authors' experience with the endovascular treatment of abdominal aortic aneurysm (AAA) with use of a self-expanding nitinol stent covered with a polyester fabric device and to report the implant's technical features, the immediate results, and the outcome 30 days after device implantation.

MATERIALS AND METHODS

From June 1997 to December 2001, we admitted 169 patients diagnosed with AAA. Of these, 134 were suitable to undergo endovascular repair with use of the Talent stent-graft. In one patient, it was technically impossible to proceed with the implantation procedure. Therefore, a total of 133 patients were treated with use of this technique (78.7%). The average age was 70.7 years (range, 52-88 y). There were 119 men and 14 women. Computed tomographic follow-up was done between the 15th and 30th postoperative days.

RESULTS

The stent-grafts were successfully implanted in all 133 patients. Complications during the procedure included three type-I endoleaks (2.3%) and four iliac artery ruptures (3.0%), which were effectively treated by means of aortic or iliac extension grafts, respectively. The average surgical time was 2.92 hours (from 1.67 h to 7 h). Of the stent-grafts used, 125 were bifurcated (94.0%), two were straight tube grafts (1.5%), and six were conical aortouniiliac grafts (4.5%). Custom-made grafts were used in 62 patients (46.6%) and standard grafts were used in 71 (53.4%). Suprarenal fixation was performed in 117 patients (88%). One female patient developed a serious pulmonary embolism. Eight patients (6.0%) developed serious systemic inflammatory syndrome; two died of disseminated intravascular coagulopathy. There were two additional deaths, one from refractory shock and one suddenly from an unknown cause (total mortality rate, 3.0%). During the postoperative period, 70.3% of the patients developed mild fever (37.6 degrees C-38.9 degrees C). The average length of stay in the intensive care unit was 1.3 days (ranging from 1 d to 12 d) and the total hospitalization time was 4.2 days. Six type-II endoleaks were observed: two were corrected by video laparoscopy-assisted inferior mesenteric artery interruption and the other four were clinically followed up.

CONCLUSIONS

The exclusion of AAA by endovascular techniques with use of the Talent device was possible in the majority of cases with a low incidence of complications. The most common serious postprocedural complication was systemic inflammatory syndrome.

Abdominal aortic aneurysms: cost-effectiveness of elective endovascular and open surgical repair

PURPOSE

To evaluate the cost-effectiveness of elective endovascular and open surgical repair of infrarenal abdominal aortic aneurysms (AAAs) by taking into account short- and long-term outcomes.

MATERIALS AND METHODS

A Markov decision model was developed to evaluate quality-adjusted life-years (QALYs) and lifetime costs of endovascular and open surgical repair. The incremental cost-effectiveness ratio (CER) was calculated for endovascular repair relative to open surgery in a cohort of 70-year-old men with an AAA between 5 and 6 cm in diameter. Clinically effectiveness data were derived from the literature. Cost data were derived from Medicare reimbursement rates, the hospital database, and the literature. One- and multiple-way sensitivity analyses were performed on uncertain model parameters. Costs were converted to year 2000 U.S. dollars; future costs and outcomes were discounted at 3%.

RESULTS

The incremental CER of endovascular repair was 9,905 dollars per QALY. QALYs and lifetime costs were higher for endovascular repair than for open surgery (6.74 vs 6.52 and 39,785 dollars vs 37,606 dollars, respectively). In sensitivity analyses, the incremental CER was insensitive to immediate conversion rate and procedure mortality rate. The incremental CER was sensitive (ie, more than 75,000 dollars per QALY or endovascular repair was ruled out by dominance) to systemic-remote complications, long-term failures, and ruptures.

CONCLUSION

The results suggest that endovascular repair is a cost-effective alternative compared with open surgery for the elective repair of AAA. The benefits and cost-effectiveness are highly dependent on uncertain outcomes, however, particularly long-term failure and rupture rates.

Elective endovascular versus open surgical repair of abdominal aortic aneurysms: systematic review of short-term results

PURPOSE

To summarize and compare published short-term results of elective endovascular and open surgical repair of abdominal aortic aneurysms.

MATERIALS AND METHODS

A MEDLINE search of the English literature was performed. Studies with at least 10 patients in each treatment group were included if they reported patient characteristics, complications, and mortality. Two reviewers independently extracted the data. A random-effects model was used to pool the data and calculate pooled odds ratios (endovascular vs open surgical repair).

RESULTS

Nine studies were included, reporting results of 1,318 procedures (687 endovascular repair and 631 open surgical repair). Mean blood loss was 456 mL for endovascular repair and 1,202 mL for open surgical repair (P =.003). On average, patients undergoing endovascular repair spent 0.5 days in the intensive care unit and 3.9 days in the hospital, and patients undergoing open surgical repair spent 2.2 days (P =.04) in the intensive care unit and 10.3 days (P =.02) in the hospital. The pooled 30-day-mortality was 0.03 for endovascular repair (95% CI: 0.02, 0.04) and 0.04 for open surgical repair (95% CI: 0.00, 0.07) (P =.03), and the odds ratio was 0.55 (95% CI: 0.33, 0.92). The pooled local and/or vascular complication rate was 0.16 for endovascular repair (95% CI: 0.06, 0.25) and 0.12 for open surgical repair (95% CI: 0.06, 0.18) (P =.46), and the odds ratio was 0.97 (95% CI: 0.62, 1.54). The pooled systemic and/or remote complication rate was 0.17 for endovascular repair (95% CI: 0.09, 0.25) and 0.44 for open surgical repair (95% CI: 0.21, 0.66) (P <.001), and the odds ratio was 0.22 (95% CI: 0.11, 0.45).

CONCLUSION

On the basis of this systematic review, endovascular repair results in less blood loss, shorter intensive care unit and hospital stays, lower 30-day mortality, and lower systemic and/or remote complication rates than those of open surgical repair.

Institutional economic losses associated with AAA repair are independent of technique

PURPOSE

To investigate the perception of significant economic loss associated with endovascular abdominal aortic aneurysm (AAA) repair by comparing economic variables for the open and endovascular techniques.

METHODS

In a 1-year period, 20 consecutive patients (19 men; mean age 73.3 years, range 62-89) were treated for uncomplicated infrarenal AAAs using conventional open repair in 11 and endovascular repair (EVR) in 9. For the open repair, standard techniques were employed, including transperitoneal and retroperitoneal exposures; in EVR, both the AneuRx and Ancure systems were utilized. Length of stay and institutional costs were carefully tracked and compared.

RESULTS

The patients were similar with regard to comorbidities, but the endograft patients were older (p=0.02) Length of stay was significantly lower in the EVR group (1.9 +/- 0.9 days) compared with the open group (8.4 +/- 4.5 days, p=0.0004). However, total mean treatment costs (open: $17,576 +/- $11,025 and EVR: $20,247 +/- $5003; p=0.51) and subsequent losses (open: -$3949 +/- $7095 and EVR: -$7572 +/- $4488; p=0.20) were not significantly different between the groups. CONCLUSIONS; The costs associated with the care of AAA patients are independent of the technique used for repair. The economic loss associated with treatment is directly related to inadequate reimbursement on the part of Medicare and other carriers.

Open infrarenal abdominal aortic aneurysm repair: the Cleveland Clinic experience from 1989 to 1998

PURPOSE

The purpose of this study was to determine the safety and durability of traditional surgical treatment for asymptomatic infrarenal abdominal aortic aneurysms (AAAs) in a large series of patients who underwent open operations during the decade preceding the commercial availability of stent graft devices for endovascular AAA repair.

METHODS

From 1989 to 1998, 1135 consecutive patients (985 men [87%], 150 women; mean age, 70 +/- 7 years) underwent elective graft replacement of infrarenal AAA. Computerized perioperative data have been supplemented with a retrospective review of hospital charts/outpatient records and a telephone canvass to calculate survival rates and the incidence rate of subsequent graft-related complications. Seventy-four patients (6.5%) were lost during a median follow-up period of 57 months for the entire series.

RESULTS

The 30-day mortality rate was 1.2%. The hospital course was completely uneventful for 939 patients (83%), and the median length of stay for all patients was 8 days. A total of 196 patients had single (n = 150; 13%) or multiple (n = 46; 4%) postoperative complications, which were more likely to occur in men (odds ratio [OR], 2.3; 95% confidence interval [CI], 1.1 to 5.2) and in patients with a history of congestive heart failure (OR, 3.7; 95% CI, 1.7 to 7.8), chronic pulmonary disease (OR, 1.9; 95% CI, 1.2 to 2.9), or renal insufficiency (OR, 2.5; 95% CI, 1.3 to 4.7). Kaplan-Meier method survival rate estimates were 75% at 5 years and 49% at 10 years. As was the case with early complications, the long-term mortality rate primarily was influenced by age of more than 75 years (risk ratio [RR], 2.2; 95% CI, 1.7 to 2.8) or previous history of congestive heart failure (RR, 2.1; 95% CI, 1.3 to 3.4), chronic pulmonary disease (RR, 1.5; 95% CI, 1.2 to 2.0), or renal insufficiency (RR, 3.2; 95% CI, 2.2 to 4.6). Of the 1047 patients who survived their operations and remained available for follow-up study, only four (0.4%) have had late complications that were related to their aortic replacement grafts.

CONCLUSION

These results reconfirm the exemplary success of open infrarenal AAA repair. The future of endovascular AAA repair is exceedingly bright, but until the long-term outcome of the current generation of stent grafts is adequately documented, their use should be justified by the presence of serious surgical risk factors.

Clinical failures of endovascular abdominal aortic aneurysm repair: incidence, causes, and management

OBJECTIVE

Despite well-documented good early results and benefits of endoluminal stent graft repair of abdominal aortic aneurysm (J Vasc Surg 2002;35:1137-44.)(AAA), the long-term outcome of this method of treatment remains uncertain. In particular, concern exists that late effectiveness and durability are inferior to that of open repair. To determine the incidence and causes of clinical failures of endovascular AAA repair, a 7-year experience with 362 primary AAA endografts was reviewed.

METHODS

Clinical failures were defined as deaths within 30 days of the procedure, conversions (early and late) to open AAA repair, AAA rupture after endoluminal treatment, or AAA sac growth of more than 5 mm in maximal diameter despite endograft repair. Endoleak status per se was not considered unless it resulted in an adverse event. If clinical problems arose but could be corrected with catheter-based therapies or limited surgical procedures, thereby maintaining the integrity of successful stent graft treatment of the AAA, such cases were considered as primary assisted success and not classified as clinical failures.

RESULTS

The average follow-up period was 1.5 years. Six deaths (1.6%) occurred after the procedure, all in elderly patients or patients at high risk. Five patients (1.4%) needed early conversion (immediate, 2 days) to open repair for access problems or technical difficulties with deployment, resulting in an implantation success rate of 98.6%. Eight patients (2.2%) underwent late conversion for a variety of problems, including AAA expansion (n = 4), endograft thrombosis (n = 1), secondary graft infection (n = 2), and rupture at 3 years (n = 1). Rupture occurred in an additional two patients for a total incidence rate of 0.8%. AAA sac growth of greater than 5 mm was observed in 20 patients (5.6%), four of whom have undergone successful catheter-based treatments to date. Overall, 39 patients (10.7%) needed catheter-based (n = 45) or limited surgical (n = 4) reinterventions for a variety of late problems that were successful in 92%.

CONCLUSION

In our 7-year experience, one or more clinical failures of endovascular AAA repair were observed in 31 patients (8.3%). Reinterventions were necessitated in a total of 10.7% of patients but were usually successful in maintaining AAA exclusion and limiting AAA growth. These results emphasize that endovascular repair provides good results and many benefits for most properly selected patients but is not as durable as standard open repair.

Safety and cost savings of endovascular procedures: are outpatient interventions feasible when combined with open surgery?

As increasing experience and comfort with endovascular interventions performed in an outpatient setting has occurred, the safety and cost effectiveness of performing these procedures without an overnight stay were analyzed, especially when endovascular procedures were combined with open vascular operations requiring an arteriotomy and surgical closure. Ninety patients underwent endovascular procedures alone or concomitantly with open, minor vascular operations to salvage a failing graft between February 1994 and June 1999. Patients undergoing endovascular interventions during primary lower extremity bypass or other major surgical procedures were not included in this review because they were not candidates for outpatient procedures. Balloon angioplasty alone (79) or angioplasty with stent placement (11) was performed to treat stenoses in 50 failing grafts, 16 iliac, 14 femoral, 5 tibial, and 5 axilla/subclavian arteries. A significant increase in outpatient procedures was accomplished as more experience was garnered with these techniques: 19% (8/42) between 1994 and 1996 vs 57% (28/48) between 1997 and 1999 (p = 0.001). Age and comorbidity did not play a role in determining the need for admission because there were no significant differences in patients with diabetes mellitus, hypertension, smoking, or hyperlipidemia and those admitted or discharged the same day (p > 0.05). Patients admitted for overnight observation tended to have longer mean operative times and more complex revascularizations than outpatients (110 vs 69 min, respectively; p < 0.0001). Twenty-seven patients underwent surgical exposure of the access vessel: 63% (17) were admitted and 37% (10) were discharged the same day. Sixty-three patients underwent a percutaneous procedure: 42% (27) were admitted and 58% (37) were discharged the same day. Outpatients were more likely to receive only local anesthesia (83%; 30/35) compared to patients admitted overnight (67%; 36/53); the remaining patients received spinal or epidural anesthesia. Complications included graft thrombosis within 30 days in 6% (5/90) of patients and arterial graft infection in 2% (2). No patient required surgery for bleeding. The average charges for outpatient interventions were $1980 compared to $10,026 for patients who stayed overnight (p < 0.0001). As vascular surgeons become more experienced and comfortable with outpatient endovascular procedures, especially when performed in combination with open minor vascular surgery, significant cost savings can be realized without sacrificing patient safety. Even when open surgical exposure is planned, patients should be instructed preoperatively to anticipate discharge the day of their procedure to minimize resistance to this strategy.

Aortic neck angulation predicts adverse outcome with endovascular abdominal aortic aneurysm repair

BACKGROUND

Significant aortic neck angulation may predispose to suboptimal outcome after endovascular abdominal aortic aneurysm (EAAA) repair. However, the definition of "significant" neck angulation and its correlation with adverse outcome are poorly characterized.

METHODS

Prospectively collected data on 148 consecutive EAAA repairs performed between December 1995 and January 2001 were supplemented with retrospective review of charts and radiographs. Aortic neck angulation was measured from arteriograms or three-dimensional computed tomography scanning reconstructions. Patients were excluded (n = 24) if radiographs were unavailable for review. Because of a paucity of severe aortic neck angulation in other endograft groups, only patients treated with a modular bifurcated device (Medtronic) (n = 81) were included in the final analysis. Mean time from implantation was 26.6 +/- 9.2 months.

RESULTS

The risk of a patient experiencing one or more adverse events was 70%, 54.5%, and 16.6% in those with severe (>or=60 degrees, n = 10), moderate (40 to 59 degrees, n = 11), and mild (<40 degrees, n = 60) aortic neck angulation, respectively (P =.0003). Adverse events included death within 30 days (20% vs 0%, P =.0007), acute conversion to open repair (20% vs 0%, P =.0007), aneurysm expansion (9.1% to 20% vs 1.7%, P =.034), device migration (20% to 30% vs 3.3%, P =.013), and type I endoleak (23.8% vs 8.3%, P =.033), all occurring with significantly greater incidence in patients with moderate or severe aortic neck angulation when compared with those with mild angulation, respectively. Aortic neck length and diameter, age, and medical comorbidities were not significantly different between groups.

CONCLUSION

Aortic neck angulation appears to be an important determinant of outcome after EAAA repair. Although patients with mild angulation (<40 degrees) had favorable outcomes in this series, those with moderate (40 to 59 degrees) or severe angulation (>or=60 degrees) had a 54% to 70% risk of one or more adverse events. Importantly, these outcomes occurred in spite of an adequate length (>2 cm) of proximal aortic neck. On the basis of these data, great caution should be exercised in recommending EAAA repair for patients with aortic neck angulation >or=40 degrees.

Durability of benefits of endovascular versus conventional abdominal aortic aneurysm repair

PURPOSE

Endovascular abdominal aortic aneurysm (AAA) repair is reported to result in less initial patient morbidity and a shorter hospital length of stay (LOS) when compared with conventional AAA repair. We sought to examine the durability of this result during the intermediate follow-up interval.

METHODS

The records of all admissions for all patients who underwent AAA repair during a 26-month interval were reviewed.

RESULTS

Three hundred thirty-seven (337) patients underwent procedures to repair AAAs (163 open and 174 endovascular). Endovascular procedures were performed with a variety of devices (Talent, 108; Ancure, 36; AneuRx, 26; Zenith, 2; and Cordis, 2) and configurations (141 bifurcated and 33 aortomonoiliac). The mean follow-up period was 10.6 months (endovascular repair) and 12.3 months (open repair). LOS did not significantly vary by device (P =.24 to P =.92) or configuration (P =.24). The initial median LOS for procedures was significantly shorter (P =.009) for endovascular repairs (5 days) than for open procedures (8 days). However, the patients who underwent endovascular repair were more likely to be readmitted during the follow-up interval when compared with patients who underwent open procedure. The readmission-free survival rate after AAA repair at 12 months was 95% for patients for open AAA repair versus 71% for patients for endovascular repair (P <.001). If the total hospital days were compared, including the initial and all subsequent AAA-related admissions, there was no significant difference for mean LOS for patients who underwent endovascular versus open AAA procedures (11 days versus 13.6 days; P =.21). The patients for endovascular AAA repair most commonly needed readmission for treatment of endoleak (n = 31), wound infection (n = 12), and graft limb thrombosis (n = 9). Although women had similar LOS to men for endovascular repair (P =.44), they had longer initial LOS for open AAA repair (15 versus 10 days; P =.03). After endovascular repair, women were more likely than men to be readmitted by 12 months (51% versus 71% readmission-free survival rate; P =.03) and they had longer LOS on readmission (13.2 versus 5.2 days; P =.006). No gender differences were identified for patients after open AAA repair regarding readmission-free survival rate (P =.09) or LOS on readmission (P =.98).

CONCLUSION

Although initial LOS was shorter for the patients who underwent endovascular as compared with conventional AAA repair, this advantage was lost during the follow-up interval because of frequent readmission for the treatment of procedure-related complications, chiefly endoleak. These readmissions frequently involved the performance of additional invasive procedures. Gender differences existed regarding LOS and the likelihood of complications after open and endovascular AAA repair.

Durability of open repair of infrarenal abdominal aortic aneurysm: a 15-year follow-up study

PURPOSE

This study reviewed the long-term outcome of patients who underwent open repair of infrarenal abdominal aortic aneurysms (AAAs).

METHODS

A retrospective study of 208 patients (188 men and 20 women) with a mean age of 65.6 years who survived elective or emergency open repair of an infrarenal AAA was conducted at a university referral hospital. Main outcome measures included late graft-related complications, survival free from any reintervention, survival free from any vascular reintervention, and overall survival rates.

RESULTS

Late graft-related complications occurred in 32 patients (15.4%). A proximal para-anastomotic pseudoaneurysm developed in six patients (2.9%), and a distal pseudoaneurysm developed in 18 patients (8.7%); in seven of these cases (3.4%), it was bilateral or recurrent. A graft limb occlusion occurred in 11 patients (5.3%). These complications required 37 surgical or other invasive procedures in 27 patients (13.0%). Thirty-one vascular and/or endovascular reoperations were performed. The 5-year, 10-year, and 15-year survival free from any reintervention rates were 91.5%, 86.2%, and 72.0%, respectively. At the same intervals, the survival free from any vascular reintervention rates were 93.8%, 88.5%, and 73.9%, respectively, and the overall survival rates were 66.8%, 39.4%, and 18.0%, respectively. Complications associated with a ruptured femoral artery pseudoaneurysm, a ruptured aortic pseudoaneurysm, an aortoduodenal fistula, and the elective repair of a femoral pseudoaneurysm were the graft-related causes of death, which occurred in four patients (1.9%). Age (P <.0001) and chronic obstructive pulmonary disease (P =.002) were shown by means of multivariate analysis to be predictive of poor survival outcome, and chronic obstructive pulmonary disease (P =.02) and lower limb ischemia (P =.04) were shown to be associated with an increased need for vascular reinterventions to treat graft-related complications.

CONCLUSION

Open repair of infrarenal AAAs can achieve satisfactory 15-year follow-up rates of survival free from reintervention for any graft-related complications, suggesting that surgery should still be considered the procedure of choice for infrarenal AAAs, at least in patients who are fit for surgery.

Abdominal aortic aneurysm repair

Newer, minimally invasive catheter-based endovascular technology utilizing stent grafts are currently being evaluated for abdominal aortic aneurysm (AAA) repair. A retrospective review of all (3 years) consecutive, non-ruptured elective AAA repairs was undertaken to document the results of AAA surgical repair in a modern cohort of patients to allow a contemporary comparison with the evolving endoluminal data. One hundred twenty-one AAAs were identified in a male veteran population. Mean age was 68.5 +/-7.7 years. Medical history review showed hypertension in 55%, heart disease in 73.5%, peripheral vascular disease in 21%, stroke and transient ischemic attacks in 22%, diabetes mellitus in 7%, renal insufficiency in 10%, and smoking history in 80%. The AAA size was documented with ultrasound (5.2 +/-1.3 cm, n=40) and computed tomography (5.6 +/-1.3 cm, n=100). Fifty-nine percent had angiography. Intraoperative end points included an operative time of 165 +/-6.3 minutes from incision to dressing placement. A Dacron tube graft was used in 78%, the remaining were Dacron bifurcated grafts. A suprarenal clamp was used in 8% for proximal aortic control with juxtarenal aneurysms. A pulmonary-artery catheter was placed in 69%. A transverse incision was used in 69% of patients and a midline incision was used in the rest. Estimated blood loss was 1505 +/-103 mL; cell saver blood returned 754 +/-53 mL; crystalloid/Hespan 4771 +/-176 mL; banked packed red blood cells 0.75 +/-0.11 U. Time to extubation was, in the operating room (78.5%), on the day of the operation (5.0%), postoperative day (POD) 1 (12.4%), POD2 (1.7%), POD3 (0.8%), and one case was performed with epidural anesthesia only. Postoperative end points included a 30-day mortality rate of 1.6% (two patients). Postoperative morbidity included wound dehiscence 0.8%; sepsis, urinary tract infection, wound infection, leg ischemia, ischemic colitis, and stroke each had an incidence of 1.6%; myocardial infarction, congestive heart failure, pneumonia, re-operation for suspected bleeding, and ileus or bowel obstruction occurred with an incidence of 3.3%. No significant increase in serum creatinine levels was noted. Time to enteral fluids/nutrition was 3.5 +/-0.08 days. Patients were out of bed to a chair or walking by 1.3 +/-0.06 days postoperatively. The length of stay in the intensive care unit (ICU) was 2.0 +/-0.12 days and postoperative hospital stay was 6.6 +/- 0.33 days. Transfusion requirement for the hospital stay was 1.6 +/-0.2 U per patient. This review highlights a cohort of male veteran patients with significant cardiac co-morbidity who have undergone repair with a conventional open technique and low mortality and morbidity rates. This group had rapid extubation, time to oral intake, and ambulation. In addition, ICU and hospital stays were relatively short.

Endovascular versus open surgical elective repair of infrarenal abdominal aortic aneurysm: predictors of patient discharge destination

PURPOSE

To evaluate patient discharge destination after elective endovascular or open surgical repair of infrarenal abdominal aortic aneurysm and to determine predictors for discharge to home or to a rehabilitation center.

MATERIALS AND METHODS

All patients electively treated for infrarenal abdominal aortic aneurysm with endovascular repair (n = 182) or open surgery (n = 274) between January 1997 and September 1999 were included. From the hospital database, information on discharge destination, patient characteristics, complications, and length of stay was retrieved. Multiple logistic regression analysis was performed to determine predictors for discharge to home or to a rehabilitation center.

RESULTS

Patient characteristics did not differ significantly between the treatment groups, with the exception of age (mean age, 75.1 vs 72.9 years in the endovascular and open surgical group, respectively; P =.005). Patient discharge destinations differed significantly between the treatment groups (P =.001). After endovascular procedures, 156 (85.7%) of 182 patients went home and 19 (10.4%) of 182 patients went to a rehabilitation center. After open surgery, 187 (68.2%) of 274 patients went home and 64 (23.4%) of 274 patients went to a rehabilitation center. The odds ratio of discharge to a rehabilitation center, instead of home, following endovascular procedures versus open surgery was 0.23 (95% CI: 0.13, 0.43).

CONCLUSION

Following elective repair of infrarenal abdominal aortic aneurysm, significantly more patients went home after an endovascular procedure than after open surgery. Procedure type was a significant predictor of discharge destination.

Hospital costs for elective endovascular and surgical repairs of infrarenal abdominal aortic aneurysms

PURPOSE

To determine and compare the average in-hospital costs of elective open surgical and endovascular repairs of infrarenal abdominal aortic aneurysms.

MATERIALS AND METHODS

Total actual cost data for patients undergoing elective endovascular (n = 181) or open surgical (n = 273) repair of abdominal aortic aneurysms between 1997 and 1999 were retrieved. The mean total hospital cost (including stent-graft costs and excluding attending physician fees) and mean postoperative length of stay were calculated for each treatment group. Costs were expressed in 1999 U.S. dollars.

RESULTS

Endovascular repair yielded a shorter postoperative length of stay than did open surgery (mean stay, 3.4 vs 8.0 days; P <.001) and a lower proportion of patients who were admitted to the intensive care unit for 1 full day or longer (2.8% vs 36.3%; P <.001). The mean total hospital cost was significantly higher for endovascular repair than for open surgery ($20,716 vs $18,484; P <.001).

CONCLUSION

Hospital costs were higher for endovascular repair than for open surgical repair. However, endovascular repair was associated with a decreased length of stay and fewer intensive care unit admissions. The increased mean hospital cost for endovascular repair was smaller than one would expect, considering the higher costs of endovascular grafts, as compared with those for surgical grafts (approximately $6,400 according to literature data).

Inpatient costs of routine endovascular repair of abdominal aortic aneurysm

RATIONALE AND OBJECTIVES

The purpose of this study was to determine the inpatient cost of routine (ie, without emergent conversion to open repair during the hospital stay) endovascular stent-graft placement in a consecutive series of patients undergoing elective endovascular repair of abdominal aortic aneurysm (AAA) at a single institution.

MATERIALS AND METHODS

Inpatient hospital costs of 91 patients who underwent initial elective endovascular repair of AAA were analyzed retrospectively. All patients had participated in clinical trials at the authors' institution during the previous 6 years. Financial data were derived from the hospital's cost-accounting system; additional procedural data were collected from a departmental database and with chart review. Stent-graft and professional costs were excluded.

RESULTS

The mean total cost for endovascular repair was $11,842 (standard deviation [SD], $5,127), mean procedure time was 149 minutes (SD, 79 minutes), and mean length of stay was 3.5 days (SD, 2.3 days). Total cost depended on stent-graft type (means, $12,428 [bifurcated] vs $9,622 [tube]; P = .0002) and strongly correlated with procedure time and length of hospital stay (r = 0.78 and 0.66, respectively; P < .0001). Ninety-six percent of total costs for all patients were attributable to the following departments: operating theater (31%), radiology (31%), nursing (22%), and anesthesia (12%).

CONCLUSION

Overall costs are greater with bifurcated than with tube stent-grafts. Total procedure-related costs are divided relatively equally between the operating theater, the radiology department, and the combination of the nursing and anesthesia departments.

Is routine use of the intensive care unit after elective infrarenal abdominal aortic aneurysm repair necessary?

INTRODUCTION

Postoperative care after infrarenal abdominal aortic aneurysm (AAA) repair has traditionally involved admission to the intensive care unit (ICU). With the advent of endovascular AAA repair, the management of open procedures has received increased scrutiny. We recently modified our AAA clinical pathway to include selective use of the ICU.

METHODS

Consecutive elective infrarenal AAA repairs performed by members of the vascular surgery division at a university medical center from 1994 to 1999 were analyzed retrospectively with a computerized database, the Medical Archival Retrieval System. Group I consisted of 245 patients who were treated in the ICU for 1 or more days, and Group II included 69 patients admitted directly to the floor. Ruptured, symptomatic, suprarenal, endovascular, and reoperative repairs were excluded. Outcome variables were compared over the 6-year period.

RESULTS

Floor admissions increased over the study period with 0%, 0%, 3.3%, 16.3%, 48.6%, and 43.6% of patients admitted directly to the surgery ward from 1994 to 1999. The average ICU length of stay declined from 4.6 to 1.2 days, whereas the hospital length of stay decreased from 12.5 to 6.8 days from 1994 to 1999. The change in ICU use had no effect on death (2.4% in Group I vs 0% in Group II). Major and minor morbidity was comparable. Hospital charges were significantly lower for patients in Group II.

CONCLUSION

A policy of selective utilization of the ICU after elective infrarenal AAA repair is safe. It can reduce resource use without a negative impact on the quality of care.