Elective Abdominal Aortic Aneurysm Repair: Relationship of Hospital Teaching Status to Repair Type, Resource Use, and Outcomes

The Year in Vascular Anesthesia: Selected Highlights From 2018

This special article is the second in an annual series for the Journal of Cardiothoracic and Vascular Anesthesia that is specifically dedicated to highlights in vascular anesthesiology published in 2018. This review begins with 2 updates in preoperative medicine in the vascular surgery population, including recent publications regarding the management of angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers and antiplatelet medications in the perioperative period. The next section focuses on complications related to thoracic endovascular aortic surgery, particularly as technology advances allow for endovascular repair of more complex anatomy. The final section focuses on quality in vascular surgery and evaluates recent publications that examine the safety and feasibility of fast-track endovascular aortic surgery. Even though this is only a sampling of the literature published in 2018 relevant to the cardiovascular anesthesiologist, these themes represent some of the topics most clinically relevant to the perioperative period.

Recent developments and current controversies in short-stay endovascular aneurysm repair

INTRODUCTION

Short stay endovascular aneurysm repair pathways (SS-EVAR) provide potential advantages to both healthcare providers and patients. However, these benefits must be carefully balanced against the inherent risks to patient safety and tariff penalties associated with unplanned readmissions.

EVIDENCE ACQUISITION

A literature review was performed using the databases MEDLINE, Embase and Cochrane Library up until March 2019. Search terms used included "endovascular aneurysm repair," "aneurysm repair," "EVAR," "abdominal aortic aneurysm," "day case," "short stay," "fast track," and "ambulatory."

EVIDENCE SYNTHESIS

Nine relevant articles (including one prior review on the topic) were identified. This early data suggests that SS-EVAR is associated with good patient satisfaction and modest cost savings for healthcare providers. Patient selection, preoperative preparation and supported discharge with early follow-up are essential components of a SS-EVAR pathway. Increasingly, SS-EVAR tends to be delivered via bilateral percutaneous access and loco-regional anesthesia. Over 70% of patients enrolled onto SS-EVAR pathways successfully complete them. Long procedures with excessive blood loss are associated with pathway non-completion. All serious complications occur within 6 hours of the procedure and the mortality (0-1%), morbidity (8-58%) and readmission rates (0-6%) associated with SS-EVAR remains acceptably low. SS-EVAR pathways can be safely and effectively implemented in both teaching and non-teaching hospitals.

CONCLUSIONS

Short-stay EVAR pathways are safe and acceptable to patients. With appropriate selection of motivated patients, successful expedited discharge can be achieved with limited readmissions, thus facilitating increased resource efficiency and cost savings for healthcare providers.

Effectiveness of open versus endovascular abdominal aortic aneurysm repair in population settings: A systematic review of statewide databases

BACKGROUND

Patient outcomes after open abdominal aortic aneurysm and endovascular aortic aneurysm repair have been widely reported from several large, randomized, controlled trials. It is not clear whether these trial outcomes are representative of abdominal aortic aneurysm repair procedures performed in real-world hospital settings across the United States. This study was designed to evaluate population-based outcomes after endovascular aortic aneurysm repair versus open abdominal aortic aneurysm repair using statewide inpatient databases and examine how they have helped improve our understanding of abdominal aortic aneurysm repair.

METHODS

A systematic search of MEDLINE, EMBASE, and CINAHL databases was performed to identify articles comparing endovascular aortic aneurysm repair and open abdominal aortic aneurysm repair using data from statewide inpatient databases. This search was limited to studies published in the English language after 1990, and abstracts were screened and abstracted by 2 authors.

RESULTS

Our search yielded 17 studies published between 2004 and 2016 that used data from 29 different statewide inpatient databases to compare endovascular aortic aneurysm repair versus open abdominal aortic aneurysm repair. These studies support the randomized, controlled trial results, including a lower mortality associated with endovascular aortic aneurysm repair extended from the perioperative period up to 3 years after operation, as well as a higher complication rate after endovascular aortic aneurysm repair. The evidence from statewide inpatient database analyses has also elucidated trends in procedure volume, patient case mix, volume-outcome relationships, and health care disparities associated with endovascular aortic aneurysm repair versus open abdominal aortic aneurysm repair.

CONCLUSION

Population analyses of endovascular aortic aneurysm repair and open abdominal aortic aneurysm repair using statewide inpatient databases have confirmed short- and long-term mortality outcomes obtained from large, randomized, controlled trials. Moreover, these analyses have allowed us to assess the effect of endovascular aortic aneurysm repair adoption on population outcomes and patient case mix over time.

Complications and death among elderly patients undergoing pituitary tumour surgery

BACKGROUND

Preoperative determinants of surgical risk in elderly patients with pituitary tumour are not fully defined. The aim of this study was to quantify operative risk for these patients.

DESIGN AND METHODS

We performed a retrospective analysis of the Nationwide Inpatient Sample (1998-2005), a database containing discharge information from a stratified, random sample of 20% of all non-federal hospitals in 37 states. Patients >65 years old who underwent pituitary tumour resection were identified by ICD-9 coding. Primary outcome was inpatient death. Other outcomes included post-operative complications, length of stay (LOS) and total charges.

RESULTS

A total of 8400 patients (53.7% male) were identified. Mean age was 72.2. Mean co-morbidity score was 5.3. A majority were white (82.0%) admitted to academic hospitals (69.5%) for elective procedures (55.7%). Inpatient mortality was 3.8%. The most common complication was fluid and electrolyte abnormalities (14.3%). Mean LOS was 8.5 days. In multivariate analysis, patients >80 years old had 30% greater odds of death, relative to 65-69 year old counterparts. Each complication increased LOS by an average of at least 4 days. These associations were statistically significant (P-values <0.05).

CONCLUSIONS

New clinically relevant risk stratification information is now available to assist clinicians in operative decision-making for elderly patients with pituitary tumour considering operative intervention.