1
|
Hawkins A, Jin R, Clouse WD, Tracci M, Weaver ML, Farivar BS. Center-level outcomes following elective fenestrated endovascular aortic aneurysm repair in the Vascular Quality Initiative database. J Vasc Surg 2024; 80:311-322. [PMID: 38604317 DOI: 10.1016/j.jvs.2024.03.453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 03/25/2024] [Accepted: 03/31/2024] [Indexed: 04/13/2024]
Abstract
OBJECTIVE Hospital volume is associated with mortality after open aortic aneurysm repair. Fenestrated and branched endovascular aortic repair (B-FEVAR) has been increasingly used for repair of complex thoracoabdominal and juxtarenal aneurysms, but evidence of a center-volume relationship is limited. We aimed to measure the association of center volume with in-hospital mortality, postoperative outcomes, and 1-year survival following B-FEVAR. METHODS Patients undergoing elective endovascular thoracoabdominal and complex abdominal aneurysm repair with branch intervention (2014-2021) listed within the national Vascular Quality Initiative Thoracic Endovascular Aortic Repair/Complex EVAR database were analyzed. Centers were grouped into quartiles by mean annual procedure volume. Multivariable regression was used to evaluate the effect of center volume on in-hospital mortality adjusting for baseline and procedural characteristics. Kaplan-Meier estimation, log rank test, and mixed effects Cox regression were used to evaluate 1-year survival. RESULTS A total of 4302 adult elective F-BEVAR procedures were identified at a total of 163 centers. In-hospital mortality did not differ by hospital volume (quartile [Q]1 = 35/1059 [3.3%]; Q2 = 30/1063 [2.8%]; Q3 = 33/1120 [2.9%]; and Q4 = 44/1060 [4.2%]; P = .308). The high volume group had a higher rate of major complication (Q1 = 14.9%; Q2 = 12.8%; Q3 = 13.3%; and Q4 = 20.1%; adjusted P < .001). Physician-modified grafts were more frequently employed in high-volume centers (Q1 = 4.5%; Q2 = 18.7%; Q3 = 11.3%; and Q4 = 19.2%; P < .001), with a decreased incidence of any endoleak noted at the end of the procedure (Q1 = 34.9%; Q2 = 32.8%; Q3 = 30.0%; and Q4 = 29.0%; P = .003). In the multivariable analysis, in-hospital mortality was not associated with center volume, comparing very low volume to medium- and high-volume centers (odds ratio [95% confidence interval] vs Q4: Q1 = 1.1 [0.6-1.9], Q2 = 0.6 [0.4-1.1], and Q3 = 0.9 [0.5-1.5]; all P > .05). No significant difference was found in 1-year survival between center volume groups. CONCLUSIONS In-hospital mortality is not associated with procedure volume within centers performing complex endovascular aortic repair. However, complication rates and endoleak may be associated with procedure volume. Long-term outcomes by annualized procedure volume, specifically graft durability and sac expansion, should be investigated.
Collapse
MESH Headings
- Humans
- Endovascular Procedures/adverse effects
- Endovascular Procedures/mortality
- Female
- Male
- Hospital Mortality
- Aged
- Databases, Factual
- Elective Surgical Procedures
- Blood Vessel Prosthesis Implantation/adverse effects
- Blood Vessel Prosthesis Implantation/mortality
- Hospitals, High-Volume
- Aortic Aneurysm, Abdominal/surgery
- Aortic Aneurysm, Abdominal/mortality
- Aortic Aneurysm, Abdominal/diagnostic imaging
- Risk Factors
- United States
- Hospitals, Low-Volume
- Retrospective Studies
- Time Factors
- Aortic Aneurysm, Thoracic/surgery
- Aortic Aneurysm, Thoracic/mortality
- Aortic Aneurysm, Thoracic/diagnostic imaging
- Treatment Outcome
- Aged, 80 and over
- Postoperative Complications/mortality
- Postoperative Complications/etiology
- Risk Assessment
- Middle Aged
Collapse
Affiliation(s)
- Andrew Hawkins
- Division of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, VA
| | - Ruyun Jin
- Division of Biostatistics, Department of Public Health Sciences, School of Medicine, University of Virginia, Charlottesville, VA
| | - W Darrin Clouse
- Division of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, VA
| | - Margaret Tracci
- Division of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, VA
| | - M Libby Weaver
- Division of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, VA
| | - Behzad S Farivar
- Division of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, VA.
| |
Collapse
|
2
|
Mohnot J, Wang Y(G, Yin K, Malas MB, Edwards NM, Dobrilovic N, Zhan Y. Changes in treatment patterns of thoracoabdominal aortic aneurysms in the United States. JTCVS OPEN 2023; 16:48-65. [PMID: 38204709 PMCID: PMC10775055 DOI: 10.1016/j.xjon.2023.08.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 07/30/2023] [Accepted: 08/29/2023] [Indexed: 01/12/2024]
Abstract
Background The introduction of endovascular repair provides an alternative to traditional open repair of thoracoabdominal aortic aneurysms (TAAA). Its utility is not well defined, however. Using a national database, we studied the treatment patterns and outcomes of TAAA to gain insight into its contemporary surgical practice in the United States. Methods Records of TAAA patients who received endovascular and open repair were retrieved from the 2002 to 2018 National Inpatient Sample database. Each cohort was stratified into 4 age groups: ≤50, 51 to 60, 61 to 70, and >70 years. Patient characteristics and in-hospital outcomes were compared between the 2 repair modalities. Temporal trends were investigated. Results Endovascular repair use increased steadily, whereas open repair volume remained stable until 2012, before declining by 50% by 2018. This appears to be associated with a declining number of open repairs in patients age >60 years. Patients who underwent endovascular repair were older and had a higher Charlson Comorbidity Index (mean, 2.8 ± 1.7 vs 2.5 ± 1.5; P < .001) but lower in-hospital mortality (mean, 8.9% vs 17.1%; P < .001), shorter length of stay (mean, 10.1 ± 12.2 days vs 17.1 ± 17.4 days; P < .001), and fewer postoperative complications. A difference in mortality between open and endovascular repair was observed for patients age >60 years but not for patients age ≤60 years. Conclusions There has been a shift in the treatment of TAAA in the United States from open repair-dominant to endovascular repair-dominant. It has increased surgical access for older and more comorbid patients and has led to a decline in the use of open repair while lowering in-hospital mortality.
Collapse
Affiliation(s)
- Joy Mohnot
- Division of Cardiothoracic Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass
| | - Yunda (George) Wang
- Division of Cardiothoracic Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass
| | - Kanhua Yin
- Department of Surgery, University of Missouri - Kansas City School of Medicine, Kansas City, Mo
| | - Mahmoud B. Malas
- Vascular and Endovascular Surgery, University of California San Diego, San Diego, Calif
| | - Niloo M. Edwards
- Division of Cardiothoracic Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass
| | - Nikola Dobrilovic
- Division of Cardiothoracic Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass
- Division of Cardiac Surgery, NorthShore University HealthSystem, Chicago, Ill
| | - Yong Zhan
- Division of Cardiac Surgery, CardioVascular Center, Tufts Medical Center, Boston, Mass
| |
Collapse
|
3
|
Teraa M, Hazenberg CEVB. The Current Era of Endovascular Aortic Interventions and What the Future Holds. J Clin Med 2022; 11:jcm11195900. [PMID: 36233768 PMCID: PMC9573386 DOI: 10.3390/jcm11195900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 10/04/2022] [Indexed: 11/16/2022] Open
Affiliation(s)
- Martin Teraa
- Correspondence: ; Tel.: +31-887556965; Fax: +31-887555017
| | | |
Collapse
|
4
|
Tenorio ER, Dias-Neto MF, Lima GBB, Baghbani-Oskouei A, Oderich GS. Lessons learned over two decades of fenestrated-branched endovascular aortic repair. Semin Vasc Surg 2022; 35:236-244. [DOI: 10.1053/j.semvascsurg.2022.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 07/12/2022] [Accepted: 07/20/2022] [Indexed: 11/11/2022]
|
5
|
Alberga A, von Meijenfeldt G, Rastogi V, de Bruin J, Wever J, van Herwaarden J. Association of Hospital Volume with Perioperative Mortality of Endovascular Repair of Complex Aortic Aneurysms: A Nationwide Cohort Study. J Vasc Surg 2022. [DOI: 10.1016/j.jvs.2022.01.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
6
|
Vasudevan TM, Sivakumaran Y. “More or less”: management of type A aortic dissections in the endovascular era. Indian J Thorac Cardiovasc Surg 2022; 38:193-197. [PMID: 35463709 PMCID: PMC8980979 DOI: 10.1007/s12055-021-01316-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 11/17/2021] [Accepted: 12/09/2021] [Indexed: 11/28/2022] Open
Abstract
The management of type A aortic dissection presents a major therapeutic challenge in modern surgical practice. Whilst the traditional dictum, to provide timely surgical intervention with the minimum treatment needed to repair the ascending aorta as well as the primary tear, may be a reasonable strategy in older patients, a tailored approach is desired for younger patients to manage the immediate life-threatening condition, as well as for the management of lifelong complications of the residual dissected aorta. Endovascular technology continues to advance, providing an adjunctive role to open cardiac repair presently to manage downstream aortic pathology, with the aim of striving towards a complete endovascular solution for type A aortic dissections.
Collapse
Affiliation(s)
| | - Yogeesan Sivakumaran
- Department of Vascular Surgery, Princess Alexandra Hospital, Brisbane, QLD Australia
| |
Collapse
|
7
|
Alberga AJ, von Meijenfeldt GCI, Rastogi V, de Bruin JL, Wever JJ, van Herwaarden JA, Hamming JF, Hazenberg CEVB, van Schaik J, Mees BME, van der Laan MJ, Zeebregts CJ, Schurink GWH, Verhagen HJM. Association of Hospital Volume with Perioperative Mortality of Endovascular Repair of Complex Aortic Aneurysms: A Nationwide Cohort Study. Ann Surg 2021; 277:00000658-900000000-93144. [PMID: 34913891 DOI: 10.1097/sla.0000000000005337] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE We evaluate nationwide perioperative outcomes of complex EVAR and assess the volume-outcome association of complex EVAR. SUMMARY OF BACKGROUND DATA Endovascular treatment with fenestrated (FEVAR) or branched (BEVAR) endografts is progressively used for excluding complex aortic aneurysms (complex AAs). It is unclear if a volume-outcome association exists in endovascular treatment of complex AAs (complex EVAR). METHODS All patients prospectively registered in the Dutch Surgical Aneurysm Audit who underwent complex EVAR (FEVAR or BEVAR) between January 2016 and January 2020 were included. The effect of annual hospital volume on perioperative mortality was examined using multivariable logistic regression analyses. Patients were stratified into quartiles based on annual hospital volume to determine hospital volume categories. RESULTS We included 694 patients (539 FEVAR patients, 155 BEVAR patients). Perioperative mortality following FEVAR was 4.5% and 5.2% following BEVAR. Postoperative complication rates were 30.1% and 48.7%, respectively. The first quartile hospitals performed <9 procedures/yr; second, third, and fourth quartile hospitals performed 9-12, 13-22, and ≥23 procedures/yr. The highest volume hospitals treated the significantly more complex patients. Perioperative mortality of complex EVAR was 9.1% in hospitals with a volume of < 9, and 2.5% in hospitals with a volume of ≥13 (P = 0.008). After adjustment for confounders, an annual volume of ≥13 was associated with less perioperative mortality compared to hospitals with a volume of < 9. CONCLUSIONS Data from this nationwide mandatory quality registry shows a significant effect of hospital volume on perioperative mortality following complex EVAR, with high volume complex EVAR centers demonstrating lower mortality rates.
Collapse
Affiliation(s)
- Anna J Alberga
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands Scientific Bureau, Dutch Institute for Clinical Auditing, Leiden, the Netherlands Department of Surgery (Division of Vascular Surgery), University Medical Center Groningen, University of Groningen, Groningen, the Netherlands Department of Vascular Surgery, Haga Teaching Hospital, The Hague, the Netherlands Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, Netherlands
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
8
|
Alhajri N, Yin K, Locham S, Ou M, Malas M. Low Volume Hospitals Are Not Associated with Inferior Outcomes After Thoracic Endovascular Aortic Repair. J Vasc Surg 2021; 75:1202-1210. [PMID: 34848350 DOI: 10.1016/j.jvs.2021.11.055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 11/07/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Thoracic endovascular aortic repair (TEVAR) has been used increasingly to treat complex thoracic aortic pathology. This study aimed to assess hospital volume's impact on outcomes in patients undergoing TEVAR. STUDY DESIGN Patients undergoing TEVAR between January 2015 and December 2019 were identified in the Vascular Quality Initiative (VQI) database. The participating centers were grouped into either low-volume hospitals (LVH) or high-volume hospitals (HVH). We assessed the impact of hospital volume on 30-day mortality and major postoperative complications using a multivariable logistic regression analysis. RESULTS A total of 3,584 TEVAR patients (asymptomatic = 1,720; symptomatic/ruptured =1,864) were identified at 147 centers. The median average annual number of TEVAR cases at LVH and HVH was 6 and 17 cases, respectively. There was no significant difference in 30-day mortality between LVH and HVH (asymptomatic: 3.7% vs. 3.7%, p = 0.98; symptomatic/rupture: 9.3% vs. 7.3%, p = 0.13). After adjusting for multiple clinical and anatomical factors, being treated in LVH was not associated with increased 30-day mortality (asymptomatic: OR = 0.98, 95% CI: 0.52, 1.87, p = 0.96; symptomatic/rupture: OR = 1.15, 95%CI: 0.75, 1.77, p = 0.53) nor an increased risk of major complications, including renal, neurological, cardiac, pulmonary, and femoral artery access complication (all p > 0.05). CONCLUSION Using a large national database, we demonstrate that LVH is not associated with inferior TEVAR outcomes than HVH. The technical aspect of the procedure might play a role in the similarity of outcomes across the different institutional experiences.
Collapse
Affiliation(s)
- Noora Alhajri
- College of Medicine and Health Sciences, Khalifa University, Abu Dhabi, United Arab Emirates; Department of Surgery, Sheikh Shakhbout Medical City (SSMC), Abu Dhabi, United Arab Emirates
| | - Kanhua Yin
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Satinderjit Locham
- Division of Vascular and Endovascular Surgery, University of California, San Diego, La Jolla, California
| | - Michael Ou
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Mahmoud Malas
- Division of Vascular and Endovascular Surgery, University of California, San Diego, La Jolla, California.
| |
Collapse
|
9
|
Outcomes of intact thoracic endovascular aortic repair in octogenarians. J Vasc Surg 2021; 74:882-892.e1. [PMID: 33600927 DOI: 10.1016/j.jvs.2021.01.039] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 01/03/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Thoracic endovascular aortic repair (TEVAR) is a suitable alternative to open aortic surgery especially for older patients with poor general health and functional status. However, data on the benefit of TEVAR in elderly patients are limited. The aim of this study was to use a large national database to compare the outcomes of TEVAR in octogenarians vs nonoctogenarians in the treatment of thoracic aortic aneurysms and dissection. METHODS All patients who underwent TEVAR for nonruptured thoracic aneurysms or dissection (zones 1-5) between January 2014 and February 2019 were identified in the Vascular Quality Initiative database. The primary outcome was in-hospital mortality. Secondary outcomes included cardiac adverse events; neurologic events; respiratory complications; new-onset dialysis; leg compartment syndrome; postoperative hematoma in addition to spinal, bowel, arm, and leg emboli/ischemia; and return to the operating room. Outcomes were compared between octogenarians (age ≥80 years) and nonoctogenarians (age <80 years) using univariable and multivariable logistic regression models. RESULTS A total of 2042 patients were identified, including 390 octogenarians (19.1%). Compared with nonoctogenarians, octogenarians had higher percentages of females (49.5% vs 40.4%; P < .01) and White patients (75.9% vs 68.6%; P < .01) and were more likely to present with thoracic aneurysms (86.2% vs 64.3%; P < .001). They also had larger aortic diameters (maximum diameter, 60.3 ± 15.8 mm vs 53.4 ± 17.4 mm), less proximal disease zones (zone 1, 3.3% vs 5.5%; zone 2, 13.9% vs 24.1%; P < .001) and were more likely to undergo the procedure under local/regional anesthesia (5.4% vs 2.4%; P < .01) compared with patients less than 80 years of age. No association was observed between octogenarians and in-hospital mortality after TEVAR for aneurysms (5.1% vs 3.3%; odds ratio [OR], 1.38; 95% confidence interval [CI], 0.72-2.61; P = .33) or dissection (5.6% vs 4.9%; OR, 0.68; 95% CI, 0.14-3.32; P = .63). However, for thoracic aneurysm repair, octogenarians had a 44% higher adjusted odds of in-hospital complications (27.4% vs 20.7%; OR, 1.44; 95% CI, 1.04-1.98; P = .03) compared with their younger counterparts. In-hospital complications (27.8% vs 26.2%; P = .79; OR, 1.02; 95% CI, 0.50-2.11; P = .95) were similar in octogenarians undergoing endovascular repair for dissections of the thoracic aorta. Octogenarians were also associated with 1.74 times the mortality hazard compared with nonoctogenarians (adjusted hazard ratio, 1.74; 95% CI, 1.18-2.58; P = .01). CONCLUSIONS TEVAR is an acceptable treatment option for octogenarians who have aortic arch and descending aortic aneurysms or dissections (zones 1-5). However, in case of aneurysms, they might be at a higher risk of in-hospital complications. Octogenarians also had increased hazard of 1-year mortality; however, the exact cause of this mortality could not be deciphered. Our findings suggest that elderly patients should not be denied TEVAR based on age if they are medically and anatomically fit for this procedure.
Collapse
|
10
|
Editor's Choice - Fenestrated or Branched Endovascular versus Open Repair for Complex Aortic Aneurysms: Meta-Analysis of Time to Event Propensity Score Matched Data. Eur J Vasc Endovasc Surg 2020; 61:228-237. [PMID: 33288434 DOI: 10.1016/j.ejvs.2020.10.010] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 07/18/2020] [Accepted: 10/07/2020] [Indexed: 11/21/2022]
Abstract
OBJECTIVE The aim of this review was to investigate comparative outcomes of fenestrated or branched endovascular aneurysm repair (F/BEVAR) with open repair for juxta/para/suprarenal or thoraco-abdominal aortic aneurysms. METHODS Electronic bibliographic sources (MEDLINE and Embase) were interrogated using the Healthcare Databases Advanced Search interface. Eligible studies compared F/BEVAR with open repair for complex aortic aneurysms using propensity score or Cox regression modelling/multivariable logistic regression analysis. Pooled estimates of peri-operative outcomes were calculated using the odds ratio (OR) and 95% confidence interval (CI). The result of time to event analysis was reported as summary hazard ratio (HR) and 95% CI. Random effects models and the inverse variance method were applied. The quality of evidence was graded using the system developed by the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) working group. RESULTS Eleven studies published between 2014 and 2019 were selected for inclusion in qualitative and quantitative synthesis reporting a total of at least 7 061 patients. The odds of peri-operative mortality after F/BEVAR were lower, although not significantly, than after open repair (OR 0.56, 95% CI 0.28-1.12), whereas the hazard of overall mortality during follow up was higher following F/BEVAR, but, again, without reaching statistical significance (HR 1.25, 95% CI 0.93-1.67). The hazard of re-intervention was significantly higher after endovascular therapy (HR 2.11, 95% CI 1.39-3.18). The certainty for the body of evidence for peri-operative and overall mortality during follow up was judged to be very low and moderate, respectively, and for re-intervention it was judged to be high. CONCLUSION The evidence is uncertain about the effect of F/BEVAR on peri-operative mortality when compared with open repair. There is probably no difference in overall survival, but F/BEVAR results in an increased re-intervention hazard. There is a need for high level evidence to inform decision making and vascular/aortic service provision.
Collapse
|