Open and endovascular elective treatment of abdominal aortic aneurysms: a real-world experience

The outcomes and cost analysis of open repair and endovascular aneurysm repair for abdominal aortic aneurysms: a single-center experience in Japan

PURPOSE

Japan has adopted its own reimbursement system, which differs from other countries in terms of its diagnostic procedure combination (DPC) methods. However, there are few reports on the cost analysis of open repair and endovascular aneurysm repair (EVAR) for abdominal aortic aneurysms in Japan. We aimed to evaluate the long-term outcomes and cost-effectiveness of these two procedures.

METHODS

This study included patients who underwent open repair (n = 224) and EVAR (n = 87) between January 2012 and December 2022. After propensity score matching, we compared the two groups.

RESULTS

The drug and blood products, procedures, and DPC costs were significantly higher in the open repair group (p < 0.001) than in the EVAR group. The surgical equipment and total costs were significantly higher in the EVAR group than in the open repair group (p < 0.001). There was no significant difference in the 5-year survival rate (88.5% in the open repair group vs. 72.0% in the EVAR group; p = 0.33) and freedom from re-intervention rate at 5 years (93.1% in the open repair group vs. 89.9% in the EVAR group; p = 0.15) between the two groups.

CONCLUSIONS

Open repair is more cost-effective than EVAR. The cost-effectiveness of EVAR may therefore depend on the cost of the endograft.

Outcomes and Cost-Analysis of Open Versus Endovascular Abdominal Aortic Aneurysm Repair in a Developing Country: A 15-year Experience at a Tertiary Medical Center

BACKGROUND

Endovascular aortic aneurysm repair (EVAR) has become the most common procedure for treating abdominal aortic aneurysms based on multiple studies conducted in the western world. The implication of such findings in developing countries is not well demonstrated. The objective of this study was to compare medical outcomes and costs of EVAR and open surgical repair (OSR) in a developing country.

METHODS

This is a retrospective study of all patients undergoing elective abdominal aortic aneurysm repair between 2005 and 2020 at a tertiary medical center in a developing country. Medical records were used to retrieve demographics, comorbidities, and perioperative complications. Medical records were also used to provide data on the need of reintervention, date of last follow-up, and mortality.

RESULTS

The study included a total of 164 patients. Median follow-up time was 41 months. The mean age was 69.9 +/- 7.84 years and 90.24% (n = 148) of patients were males. Regarding long-term mortality outcomes, no significant difference was detected between both groups; OSR patients had a survival rate of 91.38% and 74.86% at 5 and 10 years, compared to 77.29% and 56.52% in the EVAR group (P value = 0.10). Both groups had comparable long-term reintervention rates (P value = 0.334). The OSR group was charged significantly less than the EVAR group ($27,666.35 vs. $44,528.04, P value = 0.008).

CONCLUSIONS

OSR and EVAR have comparable survival and reintervention outcomes. Unlike what was reported in developed countries, patients undergoing OSR in countries with low hospital stay costs incur lower treatment costs.

Neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio predict in-hospital mortality in symptomatic but unruptured abdominal aortic aneurysm patients

BACKGROUND

Symptomatic but unruptured abdominal aortic aneurysm (AAA) is a potentially fatal disease since its etiopathogenesis, involving acute changes in the aortic wall, including inflammation, increasing the probability of impending rupture. The objective of the present study was to assess the prognostic value of the neutrophil-to-lymphocyte ratio (NLR) and the plateletto-lymphocyte ratio (PLR) in patients undergoing urgent symptomatic AAA repair.

METHODS

This was a retrospective study including 29 patients with symptomatic AAA repaired between 2011 and 2020. Both NLR and PLR were calculated on hospital admission prior to the intervention. The primary endpoint was in-hospital mortality, and the secondary endpoint included length of hospital stay and postoperative complications.

RESULTS

In-hospital mortality rate was 10.3%. The discriminatory performance to predict the primary endpoint was very good both for PLR [area under the ROC curve (AUC): 0.92 (95% confidence interval (CI): 0.82-1.00; p=0.02] and NLR [AUC: 0.88 (95% CI: 0.75-1.00); p=0.04]. The best cutoff point to predict in-hospital mortality was 185 for PLR (100% sensitivity and 85% specificity) and 6.4 for NLR (100% sensitivity and 77% specificity). The most frequent postoperative complication was acute kidney failure (37.9%). Both elevated PLR as NLR were significantly associated with acute kidney failure and multiorgan failure in the immediate postoperative period (p <0.01). None of the two ratios was associated with length of hospital stay (p=NS).

CONCLUSIONS

Both PLR and NLR are low-cost inflammatory markers widely available in every emergency department, with excellent performance to predict in-hospital mortality in patients undergoing symptomatic AAA repair. Patients with a PLR ≥185 and/or an NLR ≥6.4 could benefit from a "surveyed waiting conduct" improving the preoperative clinical condition prior to the intervention, or even considering endovascular repair.

Appropriateness of surgery performed for abdominal aortic aneurysm at tertiary hospitals in Spain

BACKGROUND

To analyze the appropriateness of the type of repair (open or endovascular) performed for abdominal aortic aneurysm (AAA) in five university hospitals in Spain, according to evidence-based recommendations.

METHODS

A multicenter, retrospective cross-sectional study of patients with AAA who underwent elective open surgical repair (OSR) or endovascular aneurysm repair (EVAR). Data were collected on demographic and clinical variables and type of surgical repair. A pair of vascular surgeons from each participating hospital performed a blinded assessment based on GRADE recommendations. The concordance between the two evaluators and the agreement between their evidence-based recommendation and the procedure actually performed were assessed.

RESULTS

A total of 186 patients were selected; 179 were included. Mean age was 72.5 years (standard deviation [SD], 8.4), mean Charlson Comorbidity Index (CCI) was 2.04 (SD, 1.9). OSR was performed in 53.2% (n=99) and EVAR in 46.8% (n=87) of cases. Overall, 65.9% (118/179) of interventions performed were considered appropriate: 50% (47/94) of OSRs and 83.5% (71/85) of EVARs. The patient characteristics were similar for all the hospitals, but the chosen surgical technique did show significant differences among these centers. There were no significant differences among the hospitals in the proportion of cases judged as appropriate, either overall (p=0.346) or for each type of procedure (p=0.531 and p=0.538 for OSR and EVAR, respectively).

CONCLUSIONS

In this study, the majority of the AAA repairs performed were appropriate according to GRADE recommendations. A higher proportion of EVARs were considered appropriate than OSRs. Choice of AAA repair should be standardized through the use of evidence-based clinical practice guidelines, while incorporating patient preferences, to reduce the existing variability and ensure appropriate selection of AAA repair technique.

Factors affecting the occurrence of proximal endoleak after endovascular abdominal aortic repair for abdominal aneurysms

Objective

This retrospective study was performed to assess the clinical and radiological variables associated with proximal type IA endoleak (EL) in patients treated with elective endovascular repair for abdominal aortic aneurysms.

Methods

The chi-square test, t-test, and logistic regression analysis were performed as appropriate. A P value of <0.05 was considered statistically significant.

Results

The data of 79 patients were analyzed. No mortality occurred. During follow-up (median, 28.5 months; interquartile range, 12.8–43.0 months), 10 patients developed type IA EL. In the logistic regression analysis, undersizing of the endograft diameter by <10% significantly affected the occurrence of type IA EL. When the diameter was used for measurements, less oversizing was significantly associated with a higher risk of type IA EL. When the area was used for measurements, oversizing of >20% significantly affected the occurrence of type IA EL.

Conclusion

When sizing endografts, a discrepancy was noted between the measurements of the diameter and area of the proximal neck. The area might represent a more accurate measurement than the axial diameter to optimize the proximal sealing and lower the risk of developing type IA EL.

Clinical evaluation of endovascular repair of abdominal aortic aneurysm based on long-term experiences

Introduction

The endovascular method as a less invasive treatment for patients with abdominal aortic aneurysm (AAA) has become an alternative to conventional open surgery.

Aim

The objective of the present study was to analyse the outcomes of endovascular treatment of AAA patients in long-term observation.

Material and methods

A group of 236 AAA patients subjected to planned endovascular aneurysm repair (EVAR) between 2010 and 2015 was reviewed. Rates of mortality, surgical complications and re-interventions were collected in the separate time periods, i.e. up to 30 days after surgery, 30 days to 3 years, and from 3 to 5 years after surgery. Cumulative rates of these parameters were evaluated in the short-term (up to 30 days after surgery), medium-term (up to 3 years), and long-term (up to 5 years after surgery) perspective.

Results

The median age of patients was 75 years, and the most common comorbidities were arterial hypertension (54%) and ischaemic heart disease (52%). Cumulative short-, medium- and long-term mortality rates were 2.5%, 14.2% and 28.9%, respectively. Total rates of surgical complications in short-, medium- and long-term observation were 7.6%, 12.6% and 17.5%, respectively. The cumulative rate of re-interventions ranged from 4.2% to 11.4%.

Conclusions

In the consecutive time periods, the increase in the percentage of surgical complications and re-interventions increased gradually, in contrast to mortality, where the curve grew significantly, which is expected due to the aging and numerous comorbidities in the observed group of patients.

Meta-analysis of long-term survival after elective endovascular or open repair of abdominal aortic aneurysm

BACKGROUND

Endovascular aneurysm repair (EVAR) has become the preferred strategy for elective repair of abdominal aortic aneurysm (AAA) for many patients. However, the superiority of the endovascular procedure has recently been challenged by reports of impaired long-term survival in patients who underwent EVAR. A systematic review of long-term survival following AAA repair was therefore undertaken.

METHODS

A systematic review was performed according to PRISMA guidelines. Articles reporting short- and/or long-term mortality of EVAR and open surgical repair (OSR) of AAA were identified. Pooled overall survival estimates (hazard ratios (HRs) with corresponding 95 per cent c.i. for EVAR versus OSR) were calculated using a random-effects model. Possible confounding owing to age differences between patients receiving EVAR or OSR was addressed by estimating relative survival.

RESULTS

Some 53 studies were identified. The 30-day mortality rate was lower for EVAR compared with OSR: 1·16 (95 per cent c.i. 0·92 to 1·39) versus 3·27 (2·71 to 3·83) per cent. Long-term survival rates were similar for EVAR versus OSR (HRs 1·01, 1·00 and 0·98 for 3, 5 and 10 years respectively; P = 0·721, P = 0·912 and P = 0·777). Correction of age inequality by means of relative survival analysis showed equal long-term survival: 0·94, 0·91 and 0·76 at 3, 5 and 10 years for EVAR, and 0·96, 0·91 and 0·76 respectively for OSR.

CONCLUSION

Long-term overall survival rates were similar for EVAR and OSR. Available data do not allow extension beyond the 10-year survival window or analysis of specific subgroups.

The Role of Duplex Ultrasound in Detecting Graft Thrombosis and Endoleak after Endovascular Aortic Repair for Abdominal Aneurysm

BACKGROUND

To assess the role of duplex ultrasound (DUS) in detecting endoleaks (ELs) and graft thrombosis (GT) in a cohort of patients submitted to endovascular aortic repair (EVAR) for elective infrarenal abdominal aortic aneurysm (AAA) in 2 centers.

METHODS

Data, of all consecutive patients treated in 2 operative units of vascular surgery, from January 01, 2000 to December 31, 2016, were retrospectively collected and evaluated. Follow-up data were analyzed to evaluate survival and device-related complications, both at 30-day and in the midterm. The results of computed tomography angiography (CTA) and DUS which were performed yearly, with a time interval between the 2 examinations lower than 30 days, were paired in terms of maximum transverse diameters of the aneurysmal sac, identification of EL, and of GT. Sensibility (SE), specificity (SP), positive predictive value (PPV), negative predictive value (NPV), and accuracy (ACC) of the DUS were calculated with respect to data of each paired CTA and to data of the real clinical diagnosis of either EL or GT. A Student's t-test was performed to compare the aneurysmal sac diameters measured with DUS to those of CTA. "Kappa" coefficient of agreement was also calculated. A P value < 0.05 was the level reference for statistical significance.

RESULTS

A total of 920 patients (104 female, 11.3%) underwent EVAR for elective infrarenal AAA. Technical success was achieved in 910 cases (98.9%). At 30 days, there were 5 deaths (0.5%), no GT, and 3 small type II ELs which did not require any adjunctive procedure. Mean follow-up was 64.8 months (range 1-120.3 months). Survival and freedom from complications were estimated to be 78.4% ± 1.9% and 48.3% ± 1.7%, respectively, at 10 years. Seventy-six more ELs and 8 GTs were recorded. Considering the CTA as the gold standard, SE, SP, and ACC of DUS in the detection of the EL were 93.2% ± 5.8%, 98.8% ± 1.1%, and 97.8%, respectively, with a PPV of 94.5% ± 5.2% and a NPV of 98.3% ± 1.4%. Considering, however, the real diagnosis of the EL, SE, SP, and ACC of DUS were slightly lower (89.4% ± 6.9%, 98.5% ± 1.3%, and 96.9%, respectively), as well as PPV and NPV (93.1% ± 5.8% and 97.7% ± 1.6%, respectively). K coefficient of agreement between the measurements of the sac maximum transverse diameter recorded at DUS and CTA was 0.91, with a little underestimation of the aneurysm diameter at DUS if compared with CTA (mean diameter difference of 2.5 mm, 95% confidence interval: 2.25-2.75 mm).

CONCLUSIONS

DUS has proven to be a reliable examination in identifying all GT and most ELs after EVAR, compared with CTA. A good correlation was also observed between the measurements of the sac maximum transverse diameter recorded at DUS and CTA, with a little underestimation of the aneurysm diameter at DUS compared with CTA.