1
|
Hafeez MS, Phillips AR, Reitz KM, Brown JB, Guyette FX, Liang NL. The Role of Integrated Air Transport System in Managing Patients with Abdominal Aortic Aneurysm Rupture. Eur J Vasc Endovasc Surg 2024; 68:201-209. [PMID: 38408516 DOI: 10.1016/j.ejvs.2024.02.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Revised: 02/05/2024] [Accepted: 02/22/2024] [Indexed: 02/28/2024]
Abstract
OBJECTIVE Ruptured abdominal aortic aneurysms (rAAAs) are highly morbid emergencies. Not all hospitals are equipped to repair them, and an air ambulance network may aid in regionalising specialty care to quaternary referral centres. The association between travel distance by air ambulance and rAAA mortality in patients transferred as an emergency for repair was examined. METHODS A retrospective review of institutional data. Adults with rAAA (2002 - 2019) transferred from an outside hospital (OSH) to a single quaternary referral centre for repair via air ambulance were identified. Patients who arrived via ground transport or post-repair at an OSH for continued critical care were excluded. Patients were divided into near and far groups based on the 75th percentile of the straight line travel distance (> 72 miles) between hospitals. The primary outcome was 30 day mortality. Multivariable logistic regression was used to assess the association between distance and mortality after adjusting for age, sex, ethnicity, cardiovascular comorbidities, and repair type. RESULTS A total of 290 patients with rAAA were transported a median distance of 40.4 miles (interquartile range 25.5, 72.7) with 215 (74.1%) near and 75 (25.9%) far patients. Both the near and far groups had similar ages, sex, and ethnicity. There was no difference in pre-operative loss of consciousness, intubation, or cardiac arrest between groups. Endovascular aneurysm repair utilisation and intra-operative aortic occlusion balloon use were also similar. Neither the observed (26.8% vs. 23.9%, p = .61) nor the adjusted odds ratio (0.70, 95% confidence interval 0.36 - 1.39, p = .32) 30 day mortality rate differed significantly between the near and far groups. CONCLUSION Increasing distance travelled during transfer by air ambulance was not associated with worse outcomes in patients with rAAA. The findings support the regionalisation of rAAA repair to large quaternary centres via an integrated and robust air ambulance network.
Collapse
Affiliation(s)
- Muhammad Saad Hafeez
- Division of Vascular Surgery, University of Pittsburgh Medical Centre, Pittsburgh, PA, USA. https://twitter.com/SaadHafeez4996
| | - Amanda R Phillips
- Division of Vascular Surgery, University of Pittsburgh Medical Centre, Pittsburgh, PA, USA
| | - Katherine M Reitz
- Division of Vascular Surgery, University of Pittsburgh Medical Centre, Pittsburgh, PA, USA
| | - Joshua B Brown
- Division of Trauma and Acute Care Surgery, University of Pittsburgh Medical Centre, Pittsburgh, PA, USA
| | - Francis X Guyette
- Department of Emergency Medicine, University of Pittsburgh Medical Centre, Pittsburgh, PA, USA
| | - Nathan L Liang
- Division of Vascular Surgery, University of Pittsburgh Medical Centre, Pittsburgh, PA, USA.
| |
Collapse
|
2
|
Meuli L, Kaufmann YL, Lattmann T, Attigah N, Dick F, Mujagic E, Papazoglou DD, Weiss S, Wyss TR, Zimmermann A. Peri-operative Mortality and Morbidity of Complex Abdominal Aortic Aneurysm Repair in Switzerland: A Swissvasc Report. Eur J Vasc Endovasc Surg 2024:S1078-5884(24)00540-9. [PMID: 38906370 DOI: 10.1016/j.ejvs.2024.06.022] [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: 01/17/2024] [Revised: 05/07/2024] [Accepted: 06/17/2024] [Indexed: 06/23/2024]
Abstract
OBJECTIVE Complex abdominal aortic aneurysms (cAAA) pose a clinical challenge. The aim of this study was to assess the 30 day mortality and morbidity rates for open aneurysm repair (OAR) and fenestrated or branched endovascular aortic repair (F/B-EVAR), and the effect of hospital volume in patients with asymptomatic cAAA in Switzerland. METHODS Retrospective, cohort study using data from Switzerland's national registry for vascular surgery, Swissvasc, including patients treated from 1 January 2019 to 31 December 2022. All patients with asymptomatic, true, non-infected cAAA were identified. The primary outcome was 30 day mortality and morbidity rates reported using the Clavien-Dindo classification. Outcomes were compared between OAR and F/B-EVAR after propensity score weighting. RESULTS Of the 461 patients identified, 333 underwent OAR and 128 underwent F/B-EVAR for cAAA. At 30 days, the overall mortality rate was 3.3% after OAR and 3.1% after F/B-EVAR (p = .76). Propensity score weighted analysis indicated similar morbidity rates for both approaches: F/B-EVAR (OR 0.69, 95% CI 0.45 - 1.05, p = .055); intestinal ischaemia (1.8% after OAR, 3.1% after F/B-EVAR, p = .47) and renal failure requiring dialysis (1.5% after OAR, 5.5% after F/B-EVAR, p = .024) were associated with highest morbidity and mortality rates. Treatment specific complications with high morbidity were abdominal compartment syndrome and lower limb compartment syndrome following F/B-EVAR. Overall treatment volume was low for most of the hospitals treating cAAA in Switzerland; outliers with increased mortality rates were identified among low volume hospitals. CONCLUSION Comparable 30 day mortality and morbidity rates were found between OAR and F/B-EVAR for cAAA in Switzerland; lack of centralisation was also highlighted. Organ specific complications driving death were renal failure, intestinal ischaemia, and limb ischaemia, specifically after F/B-EVAR. Treatment in specialised high volume centres, alongside efforts to reduce peri-procedural kidney injury and mesenteric ischaemia, offers potential to lower morbidity and mortality rates in elective cAAA treatment.
Collapse
Affiliation(s)
- Lorenz Meuli
- Department of Vascular Surgery, University Hospital Zurich (USZ), University of Zurich, (UZH), Zurich, Switzerland; Department of Vascular Surgery, Copenhagen University Hospital (Rigshospitalet), Copenhagen, Denmark.
| | - Yves L Kaufmann
- Department of Vascular Surgery, University Hospital Zurich (USZ), University of Zurich, (UZH), Zurich, Switzerland
| | - Thomas Lattmann
- Swissvasc Registry, Adjumed, Zurich, Switzerland; Department of Interventional Radiology and Vascular Surgery, Kantonsspital Winterthur, Winterthur, Switzerland
| | - Nicolas Attigah
- Vascular and Endovascular Surgery, Triemli Hospital, Zurich, Switzerland
| | - Florian Dick
- Department of Vascular Surgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Edin Mujagic
- Department of Vascular Surgery, University Hospital of Basel and University of Basel
| | - Dimitrios D Papazoglou
- Department of Vascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Salome Weiss
- Department of Vascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Thomas R Wyss
- Department of Interventional Radiology and Vascular Surgery, Kantonsspital Winterthur, Winterthur, Switzerland; Department of Vascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Alexander Zimmermann
- Department of Vascular Surgery, University Hospital Zurich (USZ), University of Zurich, (UZH), Zurich, Switzerland
| |
Collapse
|
3
|
Ribeiro TF, Soares Ferreira R, Correia R, Bastos Gonçalves F, Amaral CO, Ferreira ME. Safety of Ruptured Abdominal Aortic Aneurysm Repair Performed by Supervised Trainees as Primary Operators: Analysis of a Contemporary Propensity Score Matched Cohort. Eur J Vasc Endovasc Surg 2024; 67:1019-1020. [PMID: 38395383 DOI: 10.1016/j.ejvs.2024.02.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 01/21/2024] [Accepted: 02/20/2024] [Indexed: 02/25/2024]
Affiliation(s)
- Tiago F Ribeiro
- Hospital de Santa Marta, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
| | - Rita Soares Ferreira
- Hospital de Santa Marta, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal; NOVA Medical School | Faculdade de Ciências Médicas, NMS|FCM, Universidade Nova de Lisboa, Lisbon, Portugal
| | - Ricardo Correia
- Hospital de Santa Marta, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
| | - Frederico Bastos Gonçalves
- Hospital de Santa Marta, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal; NOVA Medical School | Faculdade de Ciências Médicas, NMS|FCM, Universidade Nova de Lisboa, Lisbon, Portugal; Hospital CUF Tejo, Lisbon, Portugal.
| | - Carlos O Amaral
- Hospital de Santa Marta, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal; NOVA Medical School | Faculdade de Ciências Médicas, NMS|FCM, Universidade Nova de Lisboa, Lisbon, Portugal
| | - Maria Emília Ferreira
- Hospital de Santa Marta, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal; NOVA Medical School | Faculdade de Ciências Médicas, NMS|FCM, Universidade Nova de Lisboa, Lisbon, Portugal
| |
Collapse
|
4
|
Bozalka R, Menges AL, Zimmermann A, Meuli L. Hospital Incidence and Treatment Outcomes of Patients with Aneurysms and Dissections of the Iliac Artery in Switzerland-A Secondary Analysis of Swiss DRG Statistics Data. J Clin Med 2024; 13:2267. [PMID: 38673541 PMCID: PMC11051054 DOI: 10.3390/jcm13082267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 04/11/2024] [Accepted: 04/12/2024] [Indexed: 04/28/2024] Open
Abstract
Background/Objectives: Aneurysms and dissections of the iliac artery (ADIAs) are significant vascular conditions often associated with aortic pathologies. Despite their importance, reports on isolated iliac artery pathologies are rare. This study aimed to investigate the epidemiology of ADIA in Switzerland including treatment incidence and hospital outcomes. Methods: A retrospective analysis of diagnosis-related group (DRG) statistics from 2011 to 2018 in Switzerland was conducted, identifying all cases of ADIA while excluding those with concomitant treatment of aortic pathologies. Age-standardized incidence rates and treatment outcomes were assessed, with multivariable logistic regression performed to identify factors associated with hospital mortality. Results: From 2011 to 2018, 1037 ADIA cases were hospitalized in Switzerland. Incidence rates for elective treatment were significantly higher in men than women, increasing in men from 1.5 to 2.4 cases per 100,000 men (p = 0.007), while remaining stable in women at around 0.2 cases per 100,000 women. Acute treatment incidence rates were lower but still higher in men, at 0.9 cases per 100,000 men and 0.2 cases per 100,000 women. Crude hospital mortality rates were lower for endovascular repair than open surgical repair in both elective (0.8% vs. 3.1%, p = 0.023) and emergency treatment (6.7% vs. 18.4%, p = 0.045). Multivariable analysis showed that endovascular repair was associated with significantly reduced hospital mortality compared to open repair (OR 0.27, 95%-CI: 0.10 to 0.66, p = 0.006). Conclusions: This nationwide study of iliac artery pathologies shows that the treatment incidence was about 10 times higher in men than in women for elective procedures, but only about five times higher for emergency treatment. Endovascular procedures were associated with significantly lower hospital mortality than open procedures, while hospital mortality rates were comparable for men and women.
Collapse
Affiliation(s)
- Roland Bozalka
- Department of Vascular Surgery, University Hospital Zurich (USZ), University of Zurich (UZH), CH-8091 Zurich, Switzerland
| | - Anna-Leonie Menges
- Department of Vascular Surgery, University Hospital Zurich (USZ), University of Zurich (UZH), CH-8091 Zurich, Switzerland
| | - Alexander Zimmermann
- Department of Vascular Surgery, University Hospital Zurich (USZ), University of Zurich (UZH), CH-8091 Zurich, Switzerland
| | - Lorenz Meuli
- Department of Vascular Surgery, University Hospital Zurich (USZ), University of Zurich (UZH), CH-8091 Zurich, Switzerland
- Copenhagen Aortic Centre, Department of Vascular Surgery, Copenhagen University Hospital, 2100 Copenhagen Ø, Denmark
| |
Collapse
|
5
|
Altreuther M. Inter-Hospital Transfer of Patients with Ruptured Abdominal Aortic Aneurysm: The International Perspective. Eur J Vasc Endovasc Surg 2024; 67:177. [PMID: 37295601 DOI: 10.1016/j.ejvs.2023.05.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Accepted: 05/19/2023] [Indexed: 06/12/2023]
Affiliation(s)
- Martin Altreuther
- St Olavs Hospital Trondheim University Hospital, Department for Vascular Surgery, Prinsesse Kristinas gate 3, Trondheim, 7030, Norway.
| |
Collapse
|
6
|
Meuli L, Reutersberg B, Zimmermann A. Response to Letter to the Editor "Inter-Hospital Transfer of Patients with Ruptured Abdominal Aortic Aneurysm: the International Perspective". Eur J Vasc Endovasc Surg 2024; 67:177-178. [PMID: 37295598 DOI: 10.1016/j.ejvs.2023.05.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 05/30/2023] [Accepted: 05/31/2023] [Indexed: 06/12/2023]
Affiliation(s)
- Lorenz Meuli
- Department of Vascular Surgery, University Hospital Zurich, Zurich, Switzerland.
| | | | | |
Collapse
|
7
|
Trenner M, Kirchhoff F, Knappich C, Heuberger S, Eckstein HH, Kuehnl A. Editor's Choice - Temporal fluctuations of hospital incidence and mortality of ruptured abdominal aortic aneurysms in Germany: A secondary data analysis of German hospital episode statistics 2009 - 2018. Eur J Vasc Endovasc Surg 2023; 66:766-774. [PMID: 37573938 DOI: 10.1016/j.ejvs.2023.08.028] [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: 01/27/2023] [Revised: 07/09/2023] [Accepted: 08/08/2023] [Indexed: 08/15/2023]
Abstract
OBJECTIVE Abdominal aortic aneurysm rupture (rAAA) is still associated with high mortality. Recent studies have shown higher incidences in autumn and winter, and worse outcomes after rAAA treatment on weekends in some countries. This study aimed to analyse seasonal, weekday, and daytime fluctuations of the hospital incidence, treatment modalities, and outcomes of rAAA, based on the most recent nationwide German real world data. METHODS A secondary data analysis of diagnosis related group statistics (2009 - 2018), obtained from the German Federal Statistical Office, was conducted. Cases encoded by a diagnosis of rAAA in conjunction with procedural codes for endovascular aortic repair (EVAR) or open aortic repair were included. Patient and procedural characteristics, comorbidities, and outcomes were analysed for seasonal (spring, summer, autumn, and winter), weekday (Monday - Sunday) and daytime (0:00 - 8:00, 8:00 -16:00, 16:00 -20:00, and 20:00 - 24:00) fluctuations by descriptive statistics and multivariable regression analyses. RESULTS Thirteen thousand and seventy patients (85% male, median age 75 years) were treated for rAAA. Endovascular aortic repair was associated with lower mortality (adjusted OR 0.40, 95% CI 0.37 - 0.44). While no significant seasonal fluctuations were found, on a weekday basis lower hospital incidences were found on Mondays (12%) and Sundays (11%) compared with other weekdays (15 - 16%). Similarly, EVAR rates were lower on Mondays and Sundays (25% and 24%, respectively) compared with other weekdays (30 - 33%). Multivariable analyses revealed higher mortality rates on Mondays and Sundays. On a daytime basis, lower EVAR rates and higher mortality rates were found during the 16:00 - 8:00 period. CONCLUSION In German hospitals, incidences and EVAR rates to treat rAAA were lowest on Mondays and Sundays. The associated overall mortality rates were highest on the respective days. Further restructuring and centralisation of AAA treatment in Germany could potentially mitigate this weekday effect.
Collapse
Affiliation(s)
- Matthias Trenner
- Department for Vascular and Endovascular Surgery, Technical University of Munich, Munich, Germany; Division of vascular medicine, St.-Josefs Hospital, Wiesbaden, Germany. https://twitter.com/matthiastrenner
| | - Felix Kirchhoff
- Department for Vascular and Endovascular Surgery, Technical University of Munich, Munich, Germany
| | - Christoph Knappich
- Department for Vascular and Endovascular Surgery, Technical University of Munich, Munich, Germany
| | - Simon Heuberger
- Department for Vascular and Endovascular Surgery, Technical University of Munich, Munich, Germany
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Technical University of Munich, Munich, Germany
| | - Andreas Kuehnl
- Department for Vascular and Endovascular Surgery, Technical University of Munich, Munich, Germany.
| |
Collapse
|
8
|
Kawczynski MJ, van Kuijk SMJ, Olsthoorn JR, Maessen JG, Kats S, Bidar E, Heuts S. Type A aortic dissection: optimal annual case volume for surgery. Eur Heart J 2023; 44:4357-4372. [PMID: 37638786 DOI: 10.1093/eurheartj/ehad551] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 07/06/2023] [Accepted: 08/02/2023] [Indexed: 08/29/2023] Open
Abstract
BACKGROUND AND AIMS The current study proposes a novel volume-outcome (V-O) meta-analytical approach to determine the optimal annual hospital case volume threshold for cardiovascular interventions in need of centralization. This novel method is applied to surgery for acute type A aortic dissection (ATAAD) as an illustrative example. METHODS A systematic search was applied to three electronic databases (1 January 2012 to 29 March 2023). The primary outcome was early mortality in relation to annual hospital case volume. Data were presented by volume quartiles (Qs). Restricted cubic splines were used to demonstrate the V-O relation, and the elbow method was applied to determine the optimal case volume. For clinical interpretation, numbers needed to treat (NNTs) were calculated. RESULTS One hundred and forty studies were included, comprising 38 276 patients. A significant non-linear V-O effect was observed (P < .001), with a notable between-quartile difference in early mortality rate [10.3% (Q4) vs. 16.2% (Q1)]. The optimal annual case volume was determined at 38 cases/year [95% confidence interval (CI) 37-40 cases/year, NNT to save a life in a centre with the optimal volume vs. 10 cases/year = 21]. More pronounced between-quartile survival differences were observed for long-term survival [10-year survival (Q4) 69% vs. (Q1) 51%, P < .01, adjusted hazard ratio 0.83, 95% CI 0.75-0.91 per quartile, NNT to save a life in a high-volume (Q4) vs. low-volume centre (Q1) = 6]. CONCLUSIONS Using this novel approach, the optimal hospital case volume threshold was statistically determined. Centralization of ATAAD care to high-volume centres may lead to improved outcomes. This method can be applied to various other cardiovascular procedures requiring centralization.
Collapse
Affiliation(s)
- Michal J Kawczynski
- Department of Cardiothoracic Surgery, Maastricht University Medical Center (MUMC+), P. Debyelaan 25, 6629HX Maastricht, Limburg, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Universiteitssingel 50, Maastricht, PO Box 616, 6200 MD, Maastricht, The Netherlands
| | - Sander M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
| | - Jules R Olsthoorn
- Department of Cardiothoracic Surgery, Maastricht University Medical Center (MUMC+), P. Debyelaan 25, 6629HX Maastricht, Limburg, The Netherlands
- Department of Cardiothoracic Surgery, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Jos G Maessen
- Department of Cardiothoracic Surgery, Maastricht University Medical Center (MUMC+), P. Debyelaan 25, 6629HX Maastricht, Limburg, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Universiteitssingel 50, Maastricht, PO Box 616, 6200 MD, Maastricht, The Netherlands
| | - Suzanne Kats
- Department of Cardiothoracic Surgery, Maastricht University Medical Center (MUMC+), P. Debyelaan 25, 6629HX Maastricht, Limburg, The Netherlands
| | - Elham Bidar
- Department of Cardiothoracic Surgery, Maastricht University Medical Center (MUMC+), P. Debyelaan 25, 6629HX Maastricht, Limburg, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Universiteitssingel 50, Maastricht, PO Box 616, 6200 MD, Maastricht, The Netherlands
| | - Samuel Heuts
- Department of Cardiothoracic Surgery, Maastricht University Medical Center (MUMC+), P. Debyelaan 25, 6629HX Maastricht, Limburg, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Universiteitssingel 50, Maastricht, PO Box 616, 6200 MD, Maastricht, The Netherlands
| |
Collapse
|