Factors Impacting Functional Health and Resource Utilization Following Abdominal Aortic Aneurysm Repair by Open and Endovascular Techniques

Preoperative predictors of nonhome discharge after fenestrated-branched endovascular repair of complex abdominal and thoracoabdominal aortic aneurysms

BACKGROUND

Nonhome discharge (NHD) has significant implications for patient counseling and discharge planning and is frequently required following fenestrated-branched endovascular aortic repair (FB-EVAR) of complex abdominal aortic aneurysms (CAAA) and thoracoabdominal aortic aneurysms (TAAA). We aimed to identify preoperative predictors of NHD after elective FB-EVAR for CAAA and TAAA and develop a risk calculator able to predict NHD.

METHODS

A retrospective review of prospectively collected data on all patients undergoing FB-EVAR between January 2007 and December 2021 at a single institution was performed. Exclusion criteria were admission from a nonhome setting, emergency and repeat FB-EVAR, and discharge to an unknown destination. The cohort was randomly split into separate development (70% of patients) and validation (30%) cohorts to develop a predictive calculator for NHD. Independent variables associated with NHD were assessed in a series of logistic regression analyses from 100 bootstrapped samples of the development set, and a model was developed using the most predictive variables. Resulting parameter estimates were applied to data in the validation set to assess model discrimination and calibration.

RESULTS

From the initial cohort of 712 FB-EVAR patients, 644 were included in the study (74% male; mean age, 75.4 ± 7.6 years), including 452 with CAAA (70%) and 192 with TAAA (30%). Early mortality occurred in eight patients (1.2%; 5 in CAAA and 3 in TAAA) and the median hospital stay was 5 days (4 for CAAA and 7 for TAAA). Ninety-seven patients (15%) had a NHD. On multivariable analysis, older age (per year, odds ratio [OR], 1.08; P < .001), female gender (OR, 3.03; P < .001), smoking (OR, 2.86; P = .01), congestive heart failure (OR, 3.05; P = .004), peripheral artery disease (OR, 1.81; P = .07), and extent I (OR, 3.17), II (OR, 2.84), and III (OR, 2.52; all P = .08) TAAAs were associated with an increased likelihood of NHD in the development set. Based on these factors, the risk calculator was developed which accurately predicts NHD in the validation set with an area under the curve of 0.7.

CONCLUSIONS

Older, female smokers with congestive heart failure and peripheral artery disease and more extensive aneurysms are at highest risk of NHD after FB-EVAR. Using only preoperative factors, our risk calculator can predict accurately who will have a NHD, allowing enhanced preoperative patient counselling and accelerated hospital discharge.

Towards Patient Centred Outcomes for Elective Abdominal Aortic Aneurysm Repair: A Scoping Review of Quality of Life Scales

OBJECTIVE

In order to better incorporate the patient's perspective in medical decision making, core outcome sets (COS) are being defined. In the field of abdominal aortic aneurysm (AAA), efforts to capture the patient's perspective focus on generic quantitative quality of life (QoL) scales. The question arises whether these quantitative scales adequately reflect the patient's perspective on QoL, and whether they can be included in the QoL aspect of COS. A scoping review of QoL assessment in the context of elective AAA repair was undertaken.

DATA SOURCES

PubMed, Embase, Web of Science, and the Cochrane Library.

REVIEW METHODS

A scoping review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines. Articles reporting QoL assessment in the context of elective AAA repair were identified. Quantitative studies (i.e., traditional QoL scales) were aligned (triangulation approach) with qualitative studies (i.e., patient perspective) to identify parallels and discrepancies. Mean Short Form 36 item survey (SF-36) scores were pooled using a random effects model to evaluate sensitivity to change.

RESULTS

Thirty-three studies were identified, of which 29 (88%) were quantitative and four (12%) qualitative. The 33 studies reported a total of 54 quantitative QoL scales; the most frequently used were the generic SF-36 (16 studies) and five dimension EuroQol (EQ-5D; eight studies). Aneurysm specific scales were reported by one study. The generic quantitative scales showed poor alignment with the patient's perspective. The aneurysm specific scales better aligned but missed "concerns regarding symptoms" and "the impact of possible outcomes/complications". "Self control and decision making", which was brought forward by patients in qualitative studies, was not captured in any of the current scales.

CONCLUSION

There is no established tool that fully captures all aspects of the patient's perspective appropriate for a COS for elective AAA repair. In order to fulfil the need for a COS for the management of^, AAA disease, a more comprehensive overview of the patient's perspective is required.

Functional status of nursing home residents before and after abdominal aortic aneurysm repair

Although many trials have evaluated abdominal aortic aneurysm (AAA) repair, the impact of these procedures on the functional status of frail elderly patients is not well-described. The effects of elective open AAA repair (OAR) and endovascular AAA repair (EVAR) and comorbidities were evaluated for their impact on functional trajectories after discharge. Medicare inpatient claims were linked with nursing home assessment data to identify elective admissions for OAR and EVAR. A functional score (range, 0-28; higher scores indicate greater impairment) was calculated before and after interventions. Logistic regression was used to develop a propensity score for receiving EVAR because residents were not randomized. Hierarchical linear modeling determined the effect of surgery on residents' function, controlling for prehospital function, hospital length of stay (LOS), stroke, and the propensity score.Fifty-two residents underwent OAR and 161 underwent EVAR. Most (65.3%) were men and 62.0% were from 76 to 85 years old. Mean LOS was 8.3 days for OAR and 5.1 days for EVAR. Of the residents, 47.4% had good prehospital function (activities of daily living [ADL] score of 0-10), and 48.4% were moderately impaired (ADL score of 11-20). Higher baseline ADL score, increased LOS, and stroke were associated with worse trajectories. Procedure type was not significantly related to postoperative function or the subsequent rate of improvement. OAR and EVAR were associated with similar initial declines and comparable postoperative trajectories, suggesting that less invasive EVAR was not associated with improved functional preservation compared with OAR. LOS was found to be higher than expected in the frail elderly after EVAR; longer stays were associated with poorer functional trajectories. Higher baseline ADL scores were significantly associated with inferior functional status after both procedures. Evaluation of preoperative function may assist physicians in predicting outcomes in this high-risk population.

Factors Affecting the Postsurgical Length of Hospital Stay in Patients with Breast Cancer

OBJECTIVE

Breast cancer is the most common malignancy and the most common cause of mortality in women worldwide. In addition to the increasing incidence of breast cancer, the length of hospital stay (LOS) after breast cancer surgery has been decreasing. Because LOS is key in determining hospital usage, the decrease in the use of hospital facilities may have implications on healthcare planning. The purpose of this study was to evaluate the factors affecting postoperative LOS in patients with breast cancer.

MATERIALS AND METHODS

Seventy-six in patients with breast cancer, who had been treated between July 2013 and December 2014 in the General Surgery Clinic of Dicle University, were included in the study. The demographic characteristics of the patients, treatment methods, histopathological features of the tumor, concomitant diseases, whether they underwent neoadjuvant chemotherapy or not, and the length of drain remaining time were retrospectively recorded.

RESULTS

There was a correlation between drain remaining time, totally removed lymph node, the number of metastatic lymph node, and LOS. LOS of patients treated with neoadjuvant chemotherapy was longer. The patients who underwent breast-conserving surgery had a shorter LOS. Linear regression analysis revealed that the drain remaining time and the number of metastatic lymph nodes were independent risk factors for LOS.

CONCLUSION

Consideration should be given to cancer screening to diagnose the patients before lymph node metastasis occurs. In addition, drains should be avoided unless required and, if used, they should be removed as early as possible for shortening LOS.

Predictors for Perioperative Outcomes following Total Laryngectomy: A University HealthSystem Consortium Discharge Database Study

OBJECTIVE

The University HealthSystem Consortium (UHC) database collects discharge information on patients treated at academic health centers throughout the United States. We sought to use this database to identify outcome predictors for patients undergoing total laryngectomy. A secondary end point was to assess the validity of the UHC's predictive risk mortality model in this cohort of patients.

STUDY DESIGN

Retrospective review.

SETTING

Academic medical centers (tertiary referral centers) and their affiliate hospitals in the United States.

SUBJECTS AND METHODS

Using the UHC discharge database, we retrieved and analyzed data for 4648 patients undergoing total laryngectomy who were discharged between October 2007 and January 2011 from all of the member institutions. Demographics, comorbidities, institutional data, and outcomes were retrieved.

RESULTS

The length of stay and overall costs were significantly higher among female patients (P < .0001), while age was a predictor of intensive care unit stay (P = .014). The overall complication rate was higher among Asians (P = .019) and in patients with anemia and diabetes compared with other comorbidities. The average institutional case load was 1.92 cases/mo; we found an inverse correlation (R = -0.47) between the institutional case load and length of stay (P < .0001). The UHC admit mortality risk estimator was found to be an accurate predictor not only of mortality (P < .0002) but also of intensive care unit admission and complication rate (P < .0001).

CONCLUSION

This study provides an overview of laryngectomy outcomes in a contemporary cohort of patients treated at academic health centers. UHC admit mortality risk is an excellent outcome predictor and a valuable tool for risk stratification in these patients.

Factors associated with longer length of hospital stay after primary elective ankle surgery for end-stage ankle arthritis

BACKGROUND

Longer length of stay in the hospital after elective surgery results in increased use of health-care resources and higher costs. Improved perioperative care permits many foot and ankle surgical procedures to be performed as day surgery. This study determined perioperative factors associated with a longer length of stay after elective total ankle replacement or ankle arthrodesis.

METHODS

Data were prospectively collected on patients who underwent open or arthroscopic ankle fusion or total ankle replacement for end-stage ankle arthritis at our institution from 2003 to 2010. Univariate and multivariable generalized linear regression models with gamma distribution and log link function were conducted with use of the length of the hospital stay as the dependent variable and preselected risk factors of age, sex, physical and mental functional scores, comorbid factors, American Society of Anesthesiologists grade, body mass index, type of surgery, duration of surgery, and surgery day of the week as the independent variables.

RESULTS

This study included 343 patients with a median length of stay of seventy-five hours (interquartile range, fifty-two to ninety-seven hours). With use of regression analyses, the variables of age, female sex, higher American Society of Anesthesiologists grade, multiple medical comorbidities, rheumatoid arthritis, lower Short Form-36 Physical Component Summary and General Health domain scores, and open surgery were significantly associated with increased length of stay. Conversely, the variables of obesity, Short Form-36 Mental Component Summary score, surgery day of the week, and surgical duration were not associated with length of stay. Two predictive models of the length of stay were developed: one included only patient-related factors, and the other included patient and surgery-related factors.

CONCLUSIONS

The patients who are identified with a higher risk of a longer length of stay may warrant better education and more focused perioperative care when designing care pathways and allocating health-care resources.

Meta-analysis of prospective trials determining the short- and mid-term effect of elective open and endovascular repair of abdominal aortic aneurysms on quality of life

Background

Repair of an abdominal aortic aneurysm (AAA) is undertaken to prevent rupture. Intervention is by either open repair (OR) or a more minimally invasive endovascular repair (EVAR). Quality-of-life (QoL) analysis is an important health outcome and a number of single studies have assessed QoL following OR and EVAR. This was a meta-analysis of published studies to assess the effect of an intervention on QoL in patients with an AAA.

Methods

A systematic literature search was undertaken for studies prospectively reporting QoL analysis in patients with an AAA undergoing elective intervention. A multivariable meta-analysis model was developed in which the outcomes were mean changes in QoL scores over time, both for all AAA repairs (OR and EVAR) and comparing OR with EVAR.

Results

Data were collated from 16 studies (14 OR, 12 EVAR). The results suggested that treating an AAA had an effect on patient-reported QoL, evident from the statistically significant changes predominantly in domains assessing physical ability and pain. QoL was affected most within the first 3 months after any form of intervention, and was more pronounced following OR. Furthermore, a deterioration in the Physical Component Summary score following an AAA repair (either OR or EVAR) was evident at 12 months after intervention.

Conclusion

Treating an AAA deleteriously affects patient-reported QoL over the first year following intervention.

Questions remain about quality of life after abdominal aortic aneurysm repair

INTRODUCTION

Morbidity and mortality have traditionally been used as key markers of surgical outcome. However, as complication rates associated with abdominal aortic aneurysm (AAA) repair decrease, subjective measures, such as quality of life (QOL), are increasingly recognized as important indicators of treatment efficacy and quality of care. This review presents the existing evidence relating to QOL changes in patients undergoing AAA repair by open repair (OR) and endovascular techniques (EVAR) and challenges current misconceptions about the relative effect of these two procedures.

METHODS

A comprehensive literature search was performed to identify studies relating to QOL or health status in AAA repair. Quality of included studies was assessed according to Scottish Intercollegiate Guidelines Network methodology.

RESULTS

Twenty-three studies satisfied the inclusion criteria. Preoperative QOL in AAA patients has been previously suggested as being worse than that of the general population, that OR patients have a worse QOL in the early postoperative period, and that EVAR patients have a worse QOL in the longer term. None of these assertions is uniformly supported in the literature. From the existing evidence, no clear conclusions can be drawn about the relative QOL benefits of OR vs EVAR.

CONCLUSIONS

There are a paucity of good-quality data relating to health status and QOL in patients undergoing AAA repair. Little is known about the prevalence of preoperative or postoperative symptoms and the degree to which these influence patient well-being. Further investigation is needed to clarify health status and QOL changes in these patients and allow clinicians to make targeted improvements in practice.

Factors influencing postoperative length of hospital stay after breast cancer surgery

As part of a feasibility study to restructure the breast cancer services in Glasgow, factors influencing 'postoperative length of stay' (LOS) and bed utilisation in patients undergoing surgery for breast cancer were examined. Data for patients admitted at five hospitals between March 2007 and February 2008 was collected prospectively. Age, socio-demographic and clinico-pathologic factors were recorded. Independent affects of variables predicting prolonged LOS were assessed using binary logistic regression analysis. Of the 519 women, 252(49%) had screen-detected cancers with a median LOS of 1 day while 267(51%) had symptomatic cancers with a median LOS of 4 days (p < 0.001). On multivariate analysis, axillary procedure performed independently influenced prolonged LOS in both screen-detected and symptomatic cancers. In symptomatic cancers, comorbidities and deprivation also had some influence. While mastectomy with or without axillary surgery utilised 51% of the bed days, a further 20% were utilised by patients having re-operations. This study has helped in the planning of ambulatory surgery services and inpatient bed requirements for patients undergoing breast cancer surgery in Glasgow.

Risk factors for postoperative cognitive and functional difficulties in abdominal aortic aneurysm patients: a three month follow-up

BACKGROUND

Cognitive impairment and deficits in functional performance are major concerns following surgery, particularly for older patients. The objective of this study was to examine predictors of postoperative cognitive and functional difficulties and explore the relationship between presurgery and postsurgery cognitive ability and functional performance.

METHODS

89 patients undergoing elective abdominal aortic aneurysm (AAA) surgery were administered a battery of cognitive measures preoperatively, at the time of discharge from hospital and 3 months postoperatively. Functional performance was evaluated by the Portland Adaptability Inventory (PAI), both pre and postsurgery. Symptoms of delirium were assessed during the first six postoperative days.

RESULTS

A diagnosis of delirium had a mild effect on functional performance 3 months postoperatively. The strongest predictors of postoperative functional performance were the level of functioning presurgery, a longer length of hospital stay and the total number of days delirious. Cognitive impairment postsurgery was predicted by presurgery cognitive measures of verbal memory and psychomotor speed performance and the total number of days delirious.

CONCLUSIONS

Functional performance outcomes for AAA patients 3 months postsurgery revealed no significant loss of functioning relative to presurgery levels, although longer length of hospital stay and greater number of days delirious was associated with somewhat poorer outcome on indicators of social and physical functioning. Cognitive impairment postoperatively was fairly mild but when it was found it was associated with number of days delirious and preoperative deficits in verbal memory and psychomotor speed.

The Impact of Hospital Volume on the Development of Infectious Complications After Elective Abdominal Aortic Surgery in the Medicare Population

Objective: A relationship exists between higher hospital volume and lower mortality, yet the impact of hospital volume on infectious complications after elective abdominal aortic aneurysm (AAA) repair is unknown. Methods: The Medicare database (2005-2007) was utilized. Top 10% for volume were categorized as high-volume (HV) and compared to low-volume (LV) centers for infectious complications and utilization. Results: A total of 42 155 endovascular aneurysm repair (EVAR) and 17 210 open AAA were identified. Mortality in HV was significantly lower than in LV after EVAR and open AAA. After EVAR, HV had lower than LV rates of overall infection (3.10% vs 3.51%; P = .021), PNA (0.94% vs 1.27%, P = .002), and sepsis (0.31% vs 0.45%; P = .03). Length of stay (LOS) and total hospital charges were significantly lower at HV compared to LV after both EVAR and open AAA. Conclusion: For Medicare beneficiaries, undergoing elective AAA repair at hospitals performing higher volume significantly reduced postoperative infectious complications and hospital resource utilization. Further analysis identifying systematic reasons for disparities may offer cost savings and improve outcomes.

Patients' experience of open repair of abdominal aortic aneurysm--preoperative information, hospital care and recovery

AIMS AND OBJECTIVES

The aim was to elucidate patients' lived experience of the care pathway of going through open surgery for abdominal aortic aneurysm.

BACKGROUND

Open surgical treatment has a great impact on patients' health-related quality of life both before and after treatment. The transition from being independent and asymptomatic to dependent on nursing care can be difficult. To facilitate this process and provide high-quality care, patients' needs must be better understood.

DESIGN

An exploratory descriptive design was chosen to describe and understand patients' lived experience.

METHOD

Audio-taped interviews were performed three months postoperatively, covering the care pathway before and after surgery. Interviews were analysed with qualitative content analysis.

RESULTS

The informants made a transition from becoming aware of the deadly risk associated with abdominal aortic aneurysm to gradually understanding the physical and emotional impact of the surgical procedure during the recovery process. The experience of not understanding fully the risks of undergoing surgery or its consequences on daily life made the informants unprepared for complications and limitations during the recovery period. Many concerns emerged, with a need for more dialogue and opportunities to understand their own care than those provided by the health care staff.

CONCLUSIONS

To facilitate the transition process, health care staff should consider patients' unpreparedness for the physical and emotional impact that can follow diagnosis and treatment for abdominal aortic aneurysm and recognise the need for dialogue to enhance participation during recovery.

RELEVANCE TO CLINICAL PRACTICE

Throughout the care pathway, patients' need for information and for opportunities to reflect on bodily and emotional reactions to the diagnosis and treatment of abdominal aortic aneurysm should be recognised by nurses and physicians to support patients getting realistic expectations of the consequences of treatment and facilitate participation in decisions concerning care and medical treatment.

Effects of study design and trends for EVAR versus OSR

Purpose:

To investigate if study design factors such as randomization, multi-center versus single center evidence, institutional surgical volume, and patient selection affect the outcomes for endovascular repair (EVAR) versus open surgical repair (OSR). Finally, we investigate trends over time in EVAR versus OSR outcomes.

Methods:

Search strategies for comparative studies were performed individually for: OVID’s MEDLINE, EMBASE, CINAHL, HAPI, and Evidence Based Medicine (EBM) Reviews (including Cochrane DSR, ACP Journal Club, DARE and CCTR), limited to 1990 and November 2006.

Results:

Identified literature: 84 comparative studies pertaining to 57,645 patients. These include 4 randomized controlled trials (RCTs), plus 2 RCTs with long-term follow-up. The other 78 comparative studies were nonrandomized with 75 reporting perioperative outcomes, of which 16 were multi-center, and 59 single-center studies. Of the single-center studies 31 were low-volume and 28 were high-volume centers. In addition, 5 studies had all patients anatomically eligible for EVAR, and 8 studies included high-risk patients only. Finally, 25 long term observational studies reported outcomes up to 3 years.

Outcomes:

Lower perioperative mortality and rates of complications for EVAR versus OSR varied across study designs and patient populations. EVAR adverse outcomes have decreased in recent times.

Conclusion:

EVAR highlights the problem of performing meta-analysis when the experience evolves over time.

A review of the in vivo and in vitro biomechanical behavior and performance of postoperative abdominal aortic aneurysms and implanted stent-grafts

Endovascular repair of abdominal aortic aneurysms has generated widespread interest since the procedure was first introduced two decades ago. It is frequently performed in patients who suffer from substantial comorbidities that may render them unsuitable for traditional open surgical repair. Although this minimally invasive technique substantially reduces operative risk, recovery time, and anesthesia usage in these patients, the endovascular method has been prone to a number of failure mechanisms not encountered with the open surgical method. Based on long-term results of second- and third-generation devices that are currently becoming available, this study sought to identify the most serious failure mechanisms, which may have a starting point in the morphological changes in the aneurysm and stent-graft. To investigate the "behavior" of the aneurysm after stent-graft repair, i.e., how its length, angulation, and diameter change, we utilized state-of-the-art ex vivo methods, which researchers worldwide are now using to recreate these failure modes.

Longitudinal Outcomes After Endovascular Repair of Abdominal Aortic Aneurysms

Objective: Endovascular abdominal aneurysm repair (EVAR) is increasingly used, but there is insufficient evaluation of long-term outcomes. Method: Retrospective cohort study using the linked Washington State hospital discharge database. Result: 3,350 patients underwent elective repair of AAA (1181 EVAR) between 2000 and 2005. EVAR patients were older and had higher comorbidity scores. The 30-day readmission rate after EVAR was 11.6%. The 30-day readmissions included cardiac complications (18.5%) and device complications (10.4%). 46% of the 30-day readmissions after EVAR underwent procedures: abdominal/ iliac angiography (7.4%), angioplasty (8.9%), and device revision (8.2%). Mean time to late interventions was 611 days. Conclusion: Readmission, reintervention, and complication rates after EVAR occur more commonly than previously described. Cardiac complications were the most common readmission. Almost half of the 30-day readmissions required a secondary intervention. Long-term complications after EVAR occurred before two years. Population-based assessment may be more reflective of “real world” complication rates after EVAR.

AAA Repair: Sociodemographic Disparities in Management and Outcomes

Objective: To evaluate sociodemographic influences on utilization and outcomes of endovascular abdominal aortic repair (EVAR) for the treatment of abdominal aortic aneurysm (AAA).

Methods: Secondary data analysis of the State Inpatient Databases for New Jersey.

Results: Between 2001 and 2006, a total of 6227 adult subjects (mean [SD] age, 73.3 [8.3] years; 77.6% male) underwent AAA repair (3167 EVAR and 3060 open surgery [OS]). Patients receiving EVAR were older than those undergoing OS (mean [SD] age, 74.2 [8.0] vs 72.4 [8.6] years) ( P < .001). Men were 1.60 (95% confidence interval [CI], 1.39-1.77) times more likely to receive EVAR than women. White subjects had the same odds of undergoing EVAR as black subjects, and white subjects had 1.60 (95% CI, 1.29-2.06) times higher odds of receiving EVAR than Hispanics. Subjects with Medicare coverage were 3.90 (96% CI, 2.28-6.59) times more likely to receive EVAR than uninsured subjects. Logistic regression analysis demonstrated that older age, male sex, and Medicare coverage were significantly associated with increased utilization of EVAR and that uninsured subjects and Hispanics are less likely to receive EVAR. Octogenarians and black subjects (odds ratios: 3.69 CI: 2.31-5.91, and 2.59 CI: 1.47-4.54 respectively) had significantly greater likelihood of death after elective AAA repair.

Conclusions: For AAA repair, significant sociodemographic disparities exist in the use of endovascular technology and in mortality. The risk of death after elective AAA repair was significantly greater for black subjects. Further analysis is warranted to delineate inequalities of vascular care for AAA and to assist in formulating policy to address these disparities.

Limited feasibility in endovascular aneurysm repair using currently available graft in Korea

Despite the wide acceptance of endovascular aneurysmal repair in patients with abdominal aortic aneurysm (EVAR), stringent morphologic criteria recommended by manufacturers may preclude this treatment in patients with AAA. The purpose of this study was to investigate how many patients are feasible by Zenith and Excluder stent graft system, which are available in Korea. Eighty-two AAA patients (71 men, mean age 70 yr) who had been treated surgically or medically from January 2005 to December 2006 were included. Criteria for morphologic suitability (MS) were examined to focus on characteristics of aneurysm; proximal and distal landing zone; angulation and involvement of both iliac artery aneurysms. Twenty-eight patients (34.1%) were feasible in Zenith stent graft and 31 patients (37.8%) were feasible in Excluder. The patients who were excluded EVAR had an average of 1.61 exclusion criteria. The main reasons for exclusion were an unfavorable proximal neck (n=34, 41.5%) and problem of distal landing zone (n=25, 30.5%). There was no statistical significance among gender, age or aneurysm size in terms of MS. Only 32 patients (39%) who had AAA were estimated to be suitable for two currently approved grafts by strict criteria. However, even unfavorable AAA patients who have severe co-morbidities will be included in EVAR in the near future. Therefore, more efforts including fine skill and anatomical understanding will be needed to meet these challenging cases.

Should Endovascular Repair Be Used for Small Abdominal Aortic Aneurysms?

The outcomes of endovascular repair for small abdominal aortic aneurysm (4.0-4.9 cm) is reported. All patients undergoing endovascular abdominal aortic aneurysm repair between 2000 and 2006 with maximal diameter 4.0 to 4.9 cm form the small aneurysm study cohort. Data were analyzed retrospectively and life-table methods were used. Of 743 endovascular repairs, 132 (17.8%) were performed for small abdominal aortic aneurysm. Perioperative complication rate was 9.1%. Freedom from aneurysm expansion was 96% at 1 year, 86% at 3 years, and 77% at 5 years. Overall survival was 98%, 93%, and 84% at 1, 3, and 5 years, respectively. Perioperative 30-day mortality was 0.8% with an aneurysm-related mortality of 1.5% at 5 years. There were no deaths from delayed aneurysm rupture. Endovascular repair of small abdominal aortic aneurysm is associated with low perioperative morbidity and mortality compared with published results for open repair, and treatment threshold can be reduced to 4 cm in selected patients.

A meta-analysis of 21 178 patients undergoing open or endovascular repair of abdominal aortic aneurysm

Background

Several studies have compared outcomes after elective open and endovascular approaches to abdominal aortic aneurysm (AAA) surgery, with varying results.

Methods

A random-effects meta-analysis was undertaken to compare operative outcomes, postoperative complications, 30-day mortality and long-term patient survival after surgery. Endpoints were compared using odds ratios (ORs), weighted mean differences (WMDs) or log hazard ratios (HRs) as appropriate.

Results

Forty-two studies comprising 21 178 patients (10 855 open; 10 323 endovascular) were included. In the elective setting (20 715 patients), the endovascular method was associated with a shorter stay in intensive care (WMD − 36 h; P &lt; 0·001) and a shorter total postoperative stay (WMD − 5·4 days; P &lt; 0·001). Cardiac (OR 1·76; P = 0·002) and respiratory (OR 4·01; P &lt; 0·001) complications were more common after open surgery. In the endovascular group, 30-day mortality was lower (OR 0·46; P &lt; 0·001). Endovascular surgery was also associated with an improved long-term aneurysm-related mortality (HR 0·39; P &lt; 0·001). For ruptured AAA (463 patients), the less invasive operation was associated with a reduced stay in intensive care (WMD − 100·4 h; P = 0·005) and a significantly lower 30-day mortality (OR 0·45; P = 0·005).

Conclusions

The endovascular repair of AAA offers a clear benefit in terms of reduction in postoperative adverse events and 30-day mortality. In the longer term, it is also associated with a reduction in aneurysm-related mortality, but not in all-cause mortality.

Predictors of prolonged length of stay after major elective head and neck surgery

OBJECTIVE/HYPOTHESIS

Longer length of stay (LOS) after elective surgery is associated with an increased use of health care resources and higher costs. The objectives of this study were to determine the perioperative factors that predict a prolonged LOS after elective major head and neck operations and to test the hypothesis that factors related to process of care (intra- and postoperative) independently predict prolonged LOS after adjustment for preoperative patient characteristics.

STUDY DESIGN

Prospective hospital-based cohort study.

METHODS

The National VA Surgical Quality Improvement Program data were accessed for seven head and neck operations: radical neck dissection (RND) (n = 398), modified RND (n = 891), total laryngectomy (n = 431), total laryngectomy with RND (n = 747), hemiglossectomy with unilateral RND (n = 201), composite resection (n = 105), and composite resection with RND (n = 312). Prolonged LOS was defined as exceeding the 75th percentile for the LOS distribution of each operation. Multivariable logistic regression analysis was performed to identify factors that predicted prolonged LOS.

RESULTS

Sixty-eight variables were analyzed among 3,050 patients who qualified for inclusion. Preoperative patient characteristics that predicted prolonged LOS were older age, poorer functional status, consumption of more than two drinks of alcohol per day, history of chronic obstructive pulmonary disease, and diabetes mellitus. Intraoperative processes that predicted prolonged LOS were a longer operative time and transfusion of erythrocytes. The postoperative variables that predicted a prolonged LOS were a return to the operating room within 30 days of the index operation and the occurrence of two or more operative complications.

CONCLUSION

Several intraoperative processes and postoperative adverse events contributed additional predictive information for prolonged LOS, after consideration of preoperative patient characteristics.