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Yu J, Khamzina Y, Kennedy J, Liang NL, Hall DE, Arya S, Tzeng E, Reitz KM. The association between frailty and outcomes following ruptured abdominal aortic aneurysm repair. J Vasc Surg 2024:S0741-5214(24)00983-2. [PMID: 38614142 DOI: 10.1016/j.jvs.2024.04.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 03/28/2024] [Accepted: 04/07/2024] [Indexed: 04/15/2024]
Abstract
OBJECTIVE Endovascular aortic repair (EVAR) is a less invasive method than the more physiologically stressful open surgical repair (OSR) for patients with anatomically appropriate abdominal aortic aneurysms (AAAs). Early postoperative outcomes are associated with both patients; physiologic reserve and the physiologic stresses of the surgical intervention. Among frail patients with reduced physiologic reserve, the stress of an aortic rupture in combination with the stress of an operative repair are less well tolerated, raising the risk of complications and mortality. This study aims to evaluate the difference in association between frailty and outcomes among patients undergoing minimally invasive EVAR and the physiologically more stressful OSR for ruptured AAAs (rAAAs). METHODS Our retrospective cohort study included adults undergoing rAAA repair in the Vascular Quality Initiative from 2010 to 2022. The validated Risk Analysis Index (RAI) (robust, ≤20; normal, 21-29; frail, 30-39; very frail, ≥40) quantified frailty. The association between the primary outcome of 1-year mortality and frailty status as well as repair type were compared using multivariable Cox models generating adjusted hazard ratios (aHRs) with 95% confidence intervals (CIs). Interaction terms evaluated the association's moderation. RESULTS We identified 5806 patients (age, 72 ± 9 years; 77% male; EVAR, 65%; robust, 6%; normal, 48%; frail, 36%; very, frail 10%) with a 53% observed 1-year mortality rate following rAAA repair. OSR (aHR, 1.43; 95% CI, 1.19-1.73) was associated with increased 1-year mortality when compared with EVAR. Increasing frailty status (frail aHR, 1.26; 95% CI, 1.00-1.59; very frail aHR, 1.64; 95% CI, 1.26-2.13) was associated with increased 1-year mortality, which was moderated by repair type (P-interaction < .05). OSR was associated with increased 1-year mortality in normal (aHR, 1.49; 95% CI, 1.20-1.87) and frail (aHR, 1.51; 95% CI, 1.20-1.89), but not among robust (aHR, 0.88; 95% CI, 0.59-1.32) and very frail (aHR, 1.29; 95% CI, 0.97-1.72) patients. CONCLUSIONS Frailty and OSR were associated with increased adjusted risk of 1-year mortality following rAAA repair. Among normal and frail patients, OSR was associated with an increased adjusted risk of 1-year mortality when compared with EVAR. However, there was no difference between OSR and EVAR among robust patients who can well tolerate the stress of OSR and among very frail patients who are unable to withstand the surgical stress from rAAA regardless of repair type.
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Affiliation(s)
- Jia Yu
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA
| | | | - Jason Kennedy
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Nathan L Liang
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA; Department of Surgery, University of Pittsburgh, Pittsburgh, PA; Department of Vascular Surgery, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA
| | - Daniel E Hall
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA; Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA; Surgery Service, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA; Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Shipra Arya
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, PA
| | - Edith Tzeng
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA; Department of Surgery, University of Pittsburgh, Pittsburgh, PA; Department of Vascular Surgery, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA
| | - Katherine M Reitz
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA; Department of Surgery, University of Pittsburgh, Pittsburgh, PA; Department of Vascular Surgery, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA.
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Onohara T, Handa N, Kawasaki M, Kasashima F, Saito T, Nakamura T, Une D, Nakai M, Shiraya S, Maeda K, Imai K, Yamamoto T, Shimoe Y, Okamoto M, Kawazu Y. Long-Term Outcomes of Endovascular Aneurysm Repair in Patients Aged ≤70 Years. Ann Vasc Dis 2024; 17:25-33. [PMID: 38628930 PMCID: PMC11018108 DOI: 10.3400/avd.oa.23-00072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 01/15/2024] [Indexed: 04/19/2024] Open
Abstract
Objectives: The efficacy of endovascular aneurysm repair (EVAR) against abdominal aortic aneurysm (AAA) in younger patients remains unknown. Hence, the current study aimed to investigate whether the aneurysm-related mortality rate of EVAR is acceptable among patients aged ≤70 years. Methods: Among 644 patients, 148 underwent EVAR (EVAR group), and 496 received open surgical repair (OSR group). The cumulative incidence rates of aneurysm-related death, any intervention, and serious aneurysm-related events after AAA repair were evaluated using the cumulative incidence function in the presence of competing risks. Results: The EVAR group had higher prevalences of several comorbidities, and overall survival for the EVAR group was significantly inferior to that of the OSR group. The cumulative incidence rates of aneurysm-related death, any intervention, and serious aneurysm-related events at 5 years were 1.5%, 11.7%, and 6.4% in the EVAR group and 1.3%, 5.3%, and 5.9% in the OSR group, respectively. EVAR was not a significant prognostic factor of aneurysm-related mortality and serious aneurysm-related events. However, it was an independent poor prognostic factor of any intervention. Conclusion: EVAR was not a significant prognostic factor of aneurysm-related mortality and serious aneurysm-related events. Therefore, it demonstrated acceptable procedure-related long-term outcomes, at least in high-risk young patients.
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Affiliation(s)
- Toshihiro Onohara
- Department of Vascular Surgery, Kyushu Medical Center, Fukuoka, Fukuoka, Japan
| | - Nobuhiro Handa
- Department of Cardiovascular Surgery, Nagara Medical Center, Gifu, Gifu, Japan
| | - Masakazu Kawasaki
- Department of Cardiovascular Surgery, Hokkaido Medical Center, Sapporo, Hokkaido, Japan
| | - Fuminori Kasashima
- Department of Cardiovascular Surgery, Kanazawa Medical Center, Kanazawa, Ishikawa, Japan
| | - Tetsuya Saito
- Department of Cardiovascular Surgery, Osaka National Hospital, Osaka, Osaka, Japan
| | - Teruya Nakamura
- Department of Cardiovascular Surgery, Osaka Minami Medical Center, Kawachinagano, Osaka, Japan
| | - Dai Une
- Department of Cardiovascular Surgery, Okayama Medical Center, Okayama, Okayama, Japan
| | - Mikizo Nakai
- Department of Cardiovascular Surgery, Okayama Medical Center, Okayama, Okayama, Japan
| | - Suguru Shiraya
- Department of Cardiovascular Surgery, Hamada Medical Center, Hamada, Shimane, Japan
| | - Kazuki Maeda
- Department of Cardiovascular Surgery, Higashihiroshima Medical Center, Higashihiroshima, Hiroshima, Japan
| | - Katsuhiko Imai
- Department of Cardiovascular Surgery, Kure Medical Center, Kure, Hiroshima, Japan
| | - Tsuyoshi Yamamoto
- Department of Cardiovascular Surgery, Iwakuni Medical Center, Iwakuni, Yamaguchi, Japan
| | - Yasushi Shimoe
- Department of Cardiovascular Surgery, Shikoku Medical Center for Children and Adults, Zentsu¯ji, Kagawa, Japan
| | - Minoru Okamoto
- Department of Cardiovascular Surgery, Kumamoto Medical Center, Kumamoto, Kumamoto, Japan
| | - Yoshikazu Kawazu
- Department of Cardiovascular Surgery, Kagoshima Medical Center, Kagoshima, Kagoshima, Japan
| | - on behalf of National Hospital Organization Network Study Group in Japan for Abdominal Aortic Aneurysm
- Department of Vascular Surgery, Kyushu Medical Center, Fukuoka, Fukuoka, Japan
- Department of Cardiovascular Surgery, Nagara Medical Center, Gifu, Gifu, Japan
- Department of Cardiovascular Surgery, Hokkaido Medical Center, Sapporo, Hokkaido, Japan
- Department of Cardiovascular Surgery, Kanazawa Medical Center, Kanazawa, Ishikawa, Japan
- Department of Cardiovascular Surgery, Osaka National Hospital, Osaka, Osaka, Japan
- Department of Cardiovascular Surgery, Osaka Minami Medical Center, Kawachinagano, Osaka, Japan
- Department of Cardiovascular Surgery, Okayama Medical Center, Okayama, Okayama, Japan
- Department of Cardiovascular Surgery, Hamada Medical Center, Hamada, Shimane, Japan
- Department of Cardiovascular Surgery, Higashihiroshima Medical Center, Higashihiroshima, Hiroshima, Japan
- Department of Cardiovascular Surgery, Kure Medical Center, Kure, Hiroshima, Japan
- Department of Cardiovascular Surgery, Iwakuni Medical Center, Iwakuni, Yamaguchi, Japan
- Department of Cardiovascular Surgery, Shikoku Medical Center for Children and Adults, Zentsu¯ji, Kagawa, Japan
- Department of Cardiovascular Surgery, Kumamoto Medical Center, Kumamoto, Kumamoto, Japan
- Department of Cardiovascular Surgery, Kagoshima Medical Center, Kagoshima, Kagoshima, Japan
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Capturing the Complexity of Open Abdominal Aortic Surgery in the Endovascular Era. J Vasc Surg 2022; 76:1520-1526. [PMID: 35714893 DOI: 10.1016/j.jvs.2022.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 05/24/2022] [Accepted: 06/03/2022] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Volume and quality benchmarks for open abdominal aortic surgery and particularly open aortic aneurysm repair (OAR) in the endovascular era are guided by the Society for Vascular Surgery (SVS) guidelines, but the Vascular Quality Initiative (VQI) OAR module fails to capture the full spectrum of complex OAR. We hypothesized that VQI-ineligible complex OAR is the dominant form of open repairs performed at a VQI-participating tertiary center. METHODS All OAR cases performed at a single tertiary care center from 2007 to 2020 were reviewed. The VQI OAR criteria were applied with exclusions (non-VQI) defined as concomitant renal bypass, clamping above the superior mesenteric artery (SMA) or celiac artery, repairs performed for trauma, anastomotic aneurysm, isolated iliac aneurysm, or infected aneurysms. Linear regression was used to assess temporal trends. RESULTS Among a total of 481 open abdominal aortic operations, 355 (74%) were OAR. The average annual OAR volume remained stable over 14 years (25 ± 6; P = .46). Non-VQI OAR comprised 54% of all cases and persisted over time (R2 = .047, P = .46). Supra-celiac clamping (35%) was often necessary. The proportion of endograft explantation cases significantly increased over time from 4% in 2007 to 20% in 2019 (P = .01). Infectious indications represented 20% (n = 70) of cases. Visceral branch grafts were performed in 16% of all cases. OAR for ruptured aneurysm constituted 10% of cases. Thirty-day mortality was significantly higher in non-VQI vs. VQI-eligible OAR cases (10% vs. 4%; P = .04). CONCLUSIONS Complex OAR comprises a majority of OAR cases in a contemporary tertiary referral hospital, yet these cases are not accounted for in the VQI. Creation of a "complex OAR" VQI module would capture these cases in a quality-driven national registry and help to better inform benchmarks for volume and outcomes in aortic surgery.
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Gibello L, Verzini F, Spalla F, Frola E, Porro L, Peluttiero I, Ripepi M, Boero M, Varetto G. Long-term outcomes of open and endovascular abdominal aortic repair in younger patients. Ann Vasc Surg 2022; 85:323-330. [PMID: 35271964 DOI: 10.1016/j.avsg.2022.02.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 02/13/2022] [Accepted: 02/18/2022] [Indexed: 11/01/2022]
Abstract
OBJECTIVES To evaluate long-term results in abdominal aortic aneurysm (AAA) surgery by either open (OAR) or endovascular (EVAR) repair in patients under 70 years of age. METHODS A retrospective analysis of a prospectively collected database of patients with age under 70 years old undergoing elective infrarenal AAA surgery between 2010 and 2018 was performed. The study population was divided into two groups: OAR and EVAR. The primary end-points were overall survival and aneurysm-related death, while secondary outcomes were need for reintervention and development of minor and major complications. RESULTS 191 patients younger than 70 years old treated for elective AAA surgery were enrolled: 157 OAR (98% males, mean age 65 ± 4 years) and 34 EVAR (94% males, mean age 66 ± 4 years). Hospital stay, 30-day mortality and need for reintervention were similar; OAR population presented higher incidence of postoperative major complications (18% vs 2.9%; p .01) while minor complications were 32% in OAR vs 21% in EVAR group (p .08). Median follow-up was 69 months for OAR (IQR 53 months) vs. 79 months (IQR 51 months) for EVAR (p .9): long-term AAA-related reinterventions were more frequent after EVAR (1.9% OAR vs. 17% EVAR; p .01) while AAA-related long-term mortality was similar in both sugroups (1.3% OAR and 3% EVAR; p .8). At univariate analysis a higher risk of reintervention was reported for conical necks in EVAR group (p .03) and for the concomitant presence of iliac aneurysms in both groups (p .01). CONCLUSIONS In our population, the presence of a conical neck is an independent predictor of EVAR failure and late reintervention, while it does not play a significant role in OAR group. For this reason, in such cases, open surgery must be considered as the first option in younger patients with a long-life expectancy.
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Affiliation(s)
- Lorenzo Gibello
- Division of Vascular Surgery, Department of Surgical Sciences, University of Turin, A.O.U. Città della Salute e della Scienza, Molinette Hospital; Turin, Italy.
| | - Fabio Verzini
- Division of Vascular Surgery, Department of Surgical Sciences, University of Turin, A.O.U. Città della Salute e della Scienza, Molinette Hospital; Turin, Italy
| | - Flavia Spalla
- Division of Vascular Surgery, Department of Surgical Sciences, University of Turin, A.O.U. Città della Salute e della Scienza, Molinette Hospital; Turin, Italy
| | - Edoardo Frola
- Division of Vascular Surgery, Department of Surgical Sciences, University of Turin, A.O.U. Città della Salute e della Scienza, Molinette Hospital; Turin, Italy
| | - Luca Porro
- Division of Vascular Surgery, Department of Surgical Sciences, University of Turin, A.O.U. Città della Salute e della Scienza, Molinette Hospital; Turin, Italy
| | - Ilaria Peluttiero
- Division of Vascular Surgery, Department of Surgical Sciences, University of Turin, A.O.U. Città della Salute e della Scienza, Molinette Hospital; Turin, Italy
| | - Matteo Ripepi
- Division of Vascular Surgery, Department of Surgical Sciences, University of Turin, A.O.U. Città della Salute e della Scienza, Molinette Hospital; Turin, Italy
| | - Michele Boero
- Division of Vascular Surgery, Department of Surgical Sciences, University of Turin, A.O.U. Città della Salute e della Scienza, Molinette Hospital; Turin, Italy
| | - Gianfranco Varetto
- Division of Vascular Surgery, Department of Surgical Sciences, University of Turin, A.O.U. Città della Salute e della Scienza, Molinette Hospital; Turin, Italy
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Morisaki K, Matsubara Y, Kurose S, Yoshino S, Yamashita S, Nakayama K, Furuyama T. Analysis of prognostic factors for postoperative complications and reinterventions after open surgical repair and endovascular aneurysm repair in patients with abdominal aortic aneurysm. Ann Vasc Surg 2021; 77:172-181. [PMID: 34416285 DOI: 10.1016/j.avsg.2021.05.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 04/28/2021] [Accepted: 05/05/2021] [Indexed: 12/20/2022]
Abstract
OBJECTIVE A definitive treatment for patients with abdominal aortic aneurysm considering age and comorbidities has not been identified. In the present study, we retrospectively validated treatment outcomes in Japanese patients and proposed the treatment strategy of open surgical repair (OSR) and endovascular aneurysm repair (EVAR). METHODS We retrospectively analyzed data for patients undergoing EVAR or OSR between 2006 and 2017. Patients with ruptured abdominal aortic aneurysm were excluded. We examined post-operative complications, operative mortality, re-intervention and prognosis. RESULTS Throughout the study period, 405 patients underwent EVAR and 176 patients underwent OSR. The percentage of patients with post-operative complications was 35.8% in the OSR group, compared with 13.1% in the EVAR group (P < 0.01). The operative mortality rate was 0.49% in the EVAR group and 0.57% in the OSR group (P = 1.00). With a multivariate analysis, age, hemodialysis, modified Frailty Index (mFI), and OSR were risk factors for post-operative complications. The 5-year re-intervention free survival rate was 63.0 % with hostile neck EVAR compared with 83.1 % with favorable neck EVAR and 86.1 % with OSR group (P < 0.01). With a multivariate analysis, hemodialysis, mFI, and hostile neck EVAR were risk factors for re-intervention. The 5-year overall survival rate was 51.9 % with hostile neck EVAR compared with 73.2 % with favorable neck EVAR and 79.0 % with OSR group (P < 0.01). With a multivariate analysis, age, mFI, and hostile neck EVAR were poor prognostic factors. CONCLUSION Age, mFI, hemodialysis and hostile neck anatomy are useful predictors of post-operative complications, re-intervention and overall survival, and could be useful for informing treatment selection between OSR and EVAR.
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Affiliation(s)
- Koichi Morisaki
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
| | - Yutaka Matsubara
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shun Kurose
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shinichiro Yoshino
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Sho Yamashita
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Ken Nakayama
- Department of Vascular Surgery, Beppu Medical Center, Oita, Japan
| | - Tadashi Furuyama
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Liang NL, Sridharan ND, Reitz KM, Eslami MH, Chaer RA, Tzeng E, Makaroun MS. New randomized controlled trials for abdominal aortic aneurysm treatment should focus on younger, good-risk patients. J Vasc Surg 2021; 73:2209. [PMID: 34024466 DOI: 10.1016/j.jvs.2020.11.053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 11/17/2020] [Indexed: 11/25/2022]
Affiliation(s)
- Nathan L Liang
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Natalie D Sridharan
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Katherine M Reitz
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Mohammad H Eslami
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Rabih A Chaer
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Edith Tzeng
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Michel S Makaroun
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
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