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Kontopodis N, Galanakis N, Charalambous S, Matsagkas M, Giannoukas AD, Tsetis D, Ioannou CV, Antoniou GA. Editor's Choice - Endovascular Aneurysm Repair in High Risk Patients: A Systematic Review and Meta-Analysis. Eur J Vasc Endovasc Surg 2022; 64:461-474. [PMID: 35872342 DOI: 10.1016/j.ejvs.2022.07.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 06/06/2022] [Accepted: 07/10/2022] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To investigate outcomes of endovascular aneurysm repair (EVAR) in high risk patients. METHODS Bibliographic sources (MEDLINE, EMBASE, CINAHL, and CENTRAL) were searched using combinations of thesaurus and free text terms. The review protocol was registered in PROSPERO (CRD42021287207) and reported according to PRISMA 2020. Pooled estimates were calculated using odds ratio (OR) or hazard ratio (HR) and 95% confidence interval (CI) applying the Mantel-Haenszel or inverse variance method. EVAR peri-operative mortality in high risk patients over time was examined with mixed effects meta-regression. The GRADE framework was used to rate the certainty of evidence. RESULTS The pooled peri-operative mortality in 18 416 high risk patients who underwent EVAR was 3% (95% CI 2.3 - 4%) and has significantly reduced over time (year of publication p = .003; median study point p = .023). The peri-operative mortality was significantly lower in high risk patients treated with EVAR compared with open repair (OR 0.64; 95% CI 0.45 - 0.92), but no significant difference was found in overall (HR 1.06; 95% CI 0.76 - 1.49) or aneurysm related mortality (HR 0.57; 95% CI 0.21 - 1.55). No significant difference was found in overall mortality between high risk patients treated with EVAR vs. no intervention (HR 0.42; 95% CI 0.14 - 1.26), but the aneurysm related mortality was significantly lower in the former (HR 0.30; 95% CI 0.14 - 0.63). The peri-operative mortality was higher in high risk than normal risk patients treated with EVAR (OR 2.33; 95% CI 1.75 - 3.10), as was the overall mortality (HR 3.50; 95% CI 2.55 - 4.80). The certainty of evidence was very low for EVAR vs. open surgery or no intervention and low for high vs. normal risk patients. CONCLUSION The EVAR peri-operative mortality in high risk patients has improved over time. Even though the aneurysm related mortality of EVAR is lower compared with no intervention, EVAR may confer no overall survival benefit.
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Affiliation(s)
- Nikolaos Kontopodis
- Vascular Surgery Department, Medical School, University of Crete, Heraklion, Greece
| | - Nikolaos Galanakis
- Interventiona Radiology Unit, Medical School, University of Crete, Heraklion, Greece
| | - Stavros Charalambous
- Interventiona Radiology Unit, Medical School, University of Crete, Heraklion, Greece; Department of Radiology, Division of Interventional Radiology, Nicosia General Hospital, Nicosia, Cyprus
| | - Miltiadis Matsagkas
- Vascular Surgery Department, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Athanasios D Giannoukas
- Vascular Surgery Department, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Dimitrios Tsetis
- Interventiona Radiology Unit, Medical School, University of Crete, Heraklion, Greece
| | - Christos V Ioannou
- Vascular Surgery Department, Medical School, University of Crete, Heraklion, Greece
| | - George A Antoniou
- Department of Vascular and Endovascular Surgery, Manchester University NHS Foundation Trust, Manchester, United Kingdom; Division of Cardiovascular Sciences, School of Medical Sciences, Manchester Academic Health Science Centre, The University of Manchester, Manchester, United Kingdom.
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Le ST, Prentice HA, Harris JE, Hsu JH, Rehring TF, Nelken NA, Hajarizadeh H, Chang RW. Decreasing Trends in Reintervention and Readmission After Endovascular Aneurysm Repair in a Multiregional Implant Registry. J Vasc Surg 2022; 76:1511-1519. [PMID: 35709865 DOI: 10.1016/j.jvs.2022.04.054] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 04/12/2022] [Accepted: 04/24/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVES As endovascular aortic aneurysm repair (EVAR) matures into its third decade, measures such as long-term reintervention and readmission have become a focus of quality improvement efforts. Within a large United States integrated healthcare system, we describe time trends in the rates of long-term reinterventions utilization measures. METHODS Data from a US multiregional EVAR registry was used to perform a descriptive study of 3,891 adults who underwent conventional infrarenal EVAR for infrarenal abdominal aortic aneurysm between 2010 to 2019. Three-year follow-up was 96.7%. Outcomes included 1-, 3-, and 5-year graft revision (defined as a procedure involving placement of a new endograft component), secondary interventions (defined as a procedure necessary for maintenance of EVAR integrity, e.g., coil embolization and balloon angioplasty/stenting), conversion to open, interventions for type II endoleaks alone, and 90-day readmission. Crude cause-specific reintervention probabilities were calculated by operative year using the Aalen-Johansen estimator, with death as a competing risk and December 31, 2020 as the study end date. RESULTS Excluding interventions for type II endoleak alone, 1-year secondary intervention incidence decreased from 5.9% for EVARs in 2010 to 2.0% in 2019 (p<0.001) and 3-year incidence decreased from 7.2% to 3.6% from 2010 to 2017 (p=0.03). The 3-year incidences of graft revision (mean incidence 3.4%) and conversion to open remained fairly stable (mean incidence 0.6%) over time. The 3-year incidence of interventions for type II endoleak alone also decreased from 3.4% in 2010 to 0.7% in 2017 (p=0.01). 90-day readmission rates decreased from 19.3% for index EVAR in 2010 to 9.2% in 2019 (p=0.03). CONCLUSIONS Comprehensive data from a multiregional healthcare system demonstrates decreasing long-term secondary intervention and readmission rates over time in patients undergoing EVAR. These trends are not explained by evolving management of type II endoleaks and suggest improving graft durability, patient selection or surgical technique. Further study is needed to define implant and anatomic predictors of different types of long-term reintervention.
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Affiliation(s)
- Sidney T Le
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA; Department of Surgery, University of California San Francisco - East Bay, Oakland, CA, USA.
| | | | - Jessica E Harris
- Surgical Outcomes and Analysis, Kaiser Permanente, San Diego, CA, USA
| | - Jeffrey H Hsu
- Department of Vascular Surgery, Southern California Permanente Medical Group, Fontana, CA, USA
| | - Thomas F Rehring
- Department of Vascular Surgery, Colorado Permanente Medical Group, Denver, CO, USA
| | - Nicolas A Nelken
- Department of Vascular Surgery, Hawaii Permanente Medical Group, Honolulu, HI, USA
| | - Homayon Hajarizadeh
- Department of Vascular Surgery, Northwest Permanente Physicians and Surgeons, Clackamas, OR, USA
| | - Robert W Chang
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA; Department of Vascular Surgery, The Permanente Medical Group, South San Francisco, CA, USA.
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Ahn S. Adjunctive Procedures for Challenging Endovascular Abdominal Aortic Repair: When Needed and How Effective? Vasc Specialist Int 2020; 36:7-14. [PMID: 32274372 PMCID: PMC7119153 DOI: 10.5758/vsi.2020.36.1.7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 03/11/2020] [Accepted: 03/11/2020] [Indexed: 11/20/2022] Open
Abstract
Endovascular aneurysm repair (EVAR) is now considered the first choice treatment modality for abdominal aortic aneurysm (AAA) treatment. Advocates for endovascular strategies will try to treat all AAA by EVAR, regardless if the anatomy is conducive for treatment or not. However, the long-term outcomes of EVAR outside the instructions for use (IFU) due to a hostile aneurysmal neck or iliac artery anatomy are known to be poor. The EVAR procedures can be classified according to the technical difficulty, IFU, and need for visceral revascularization: standard, adjunctive, and complex EVAR. The situation required for adjunctive procedures can be classified as the following four steps: a hostile neck (i.e., short or severely angled); large inferior mesenteric or lumbar artery; tough iliac artery anatomy, such as a short common iliac artery and stenotic external iliac artery; and limitations in vascular access. This article will discuss the adjunctive procedures to overcome hostile aneurysm neck and unsuitable iliac artery anatomy.
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Affiliation(s)
- Sanghyun Ahn
- Division of Vascular Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
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Kalra K, Arya S. A comparative review of open and endovascular abdominal aortic aneurysm repairs in the national operative quality improvement database. Surgery 2017; 162:979-988. [DOI: 10.1016/j.surg.2017.04.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 04/11/2017] [Indexed: 01/25/2023]
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Abstract
Abdominal aortic pathology is a diverse topic, ranging through a broad span of possible pathologies. The treatment options are equally vast, particularly with the ever-expanding endovascular techniques. In this article, we discuss management strategies for abdominal aortic aneurysms and aortic occlusive disease, because they represent some of the most common pathologies encountered in clinical scenarios.
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Affiliation(s)
- Karol Meyermann
- Division of Vascular Surgery, Department of Surgery, Cooper University Hospital, Suite 411, 3 Cooper Plaza, Camden, NJ 08103, USA
| | - Francis J Caputo
- Division of Vascular Surgery, Department of Surgery, Cooper University Hospital, Suite 411, 3 Cooper Plaza, Camden, NJ 08103, USA.
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Kulig P, Lewandowski K, Ziaja D, Zaniewski M, Kulig J. Endovascular Aneurysm Repair or Open Aneurysm Repair for the Treatment of Abdominal Aortic Aneurysm - The Latest Update. POLISH JOURNAL OF SURGERY 2017; 88:166-74. [PMID: 27428840 DOI: 10.1515/pjs-2016-0047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Indexed: 11/15/2022]
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Abstract
Objective: To assess medical economic adequacy of endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA). Methods: Cost-utility analysis. A total of 21 patients with AAA treated at Ibaraki Prefectural Central Hospital in 2014 were divided into non-ruptured EVAR (Group E) and open surgery (OS) (Group O), and ruptured OS (Group R) groups, and hospital costs were aggregated with a medical accounting system. Mid-level hospital costs were estimated by a diagnosis-procedure-combination analysis system. Incremental life years were extrapolated from the results of randomized controlled trials in the UK (EVAR Trial 1 and 2), a life table, and the Pancreas Cancer Registry in Japan. Quality-adjusted life years (QALY) were estimated under the assumption of a certain quality weight. Results: Incremental cost-effectiveness ratio (ICER) of EVAR compared with the OS was calculated to be 31.0 million yen/QALY, which is economically inadequate. ICER of EVAR compared with conservative treatment was inadequate in some subgroups of extremely old patients and in patients operated for far-advanced cancer. Conclusion: EVAR is inadequate with respect to medical economics as a substitute for OS for patients in whom both procedures are available. The indication for EVAR in patients ineligible for OS should be different from that for surgery in usual patients with AAA. (This is a translation of J Jpn Coll Angiol 2016; 56: 123–130.)
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Affiliation(s)
- Yutaka Takayama
- Department of Vascular Surgery, Ibaraki Prefectural Central Hospital, Kasama, Ibaraki, Japan
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Manunga J, Titus J. Regional anesthesia as the anesthetic of choice for high-risk surgical patients undergoing repair of juxtarenal aortic aneurysms with fenestrated stent grafts. J Vasc Surg 2016; 65:1820-1822. [PMID: 27887855 DOI: 10.1016/j.jvs.2016.08.117] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Accepted: 08/31/2016] [Indexed: 10/20/2022]
Abstract
Juxtarenal aortic aneurysms (JAAs) have been conventionally treated using open repair with excellent results. Recent approval of fenestrated stent grafts by the United States Food and Drug Administration has given patients with JAAs an alternative for repair. However, most of these procedures are still performed under general anesthesia, making some surgeons reluctant to offer repair to a subset of patients deemed too high risk for general anesthesia. We present three patients with JAAs at high surgical risk, including one patient with a ruptured aneurysm, who were successfully treated using a fenestrated stent graft under regional anesthesia.
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Affiliation(s)
- Jesse Manunga
- Department of Vascular and Endovascular Surgery, Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minn.
| | - Jessica Titus
- Department of Vascular and Endovascular Surgery, Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minn
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Mousa AY, Bozzay J, Broce M, Yacoub M, Stone PA, Najundappa A, Bates MC, AbuRahma AF. Novel Risk Score Model for Prediction of Survival Following Elective Endovascular Abdominal Aortic Aneurysm Repair. Vasc Endovascular Surg 2016; 50:261-9. [PMID: 27114446 DOI: 10.1177/1538574416638760] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The purpose of this study was to identify significant predictors of long-term mortality after elective endovascular abdominal aortic aneurysm repair (EVAR). METHODS We included all cases with elective EVAR based on a national data set from the Society for Vascular Surgery Patient Safety Organization. Clinical and anatomic variables were analyzed with a Kaplan-Meier and Cox-regression model to determine predictors of mortality and develop a score equation to categorize patients into low, medium, and high long-term mortality risk. RESULTS A total of 5678 patients with EVAR were included with an average age of 73.6 ± 8.2 years. The majority were male (81.6%) with a history of smoking (86.1%). There were 3 deaths within 30 days (0.1%). Several factors were associated with poor survival: unstable angina (hazard ratio [HR], 2.8; P = .008), dialysis (HR, 3.7; P < .001), estimated glomerular filtration rate (eGFR) <30 (HR, 1.7; P = .044), eGFR 30 to 59 (HR, 1.4; P = .002), age >80 (HR, 3.2; P < .001), age 75 to 79 (HR, 2.2; P < .001), chronic obstructive pulmonary disease on oxygen (HR, 3.3; P < .001), aortic diameter >5.8 cm (HR, 1.2; P = .043), and high risk for surgery (HR, 1.4; P = .043). Preoperative aspirin use and body mass index 25 to 35 were both found to be protective (HR, 0.78; P = .017 and HR, 0.8; P = .024, respectively). With our scoring model, 5- and 10-year survival rates for patients with low, medium, and high risk were 89.2%, 80.7%, and 64.1% and 77.2%, 60.1%, and 40.1%, respectively (P < .001). CONCLUSION Ten-year survival following EVAR in patients with a high-risk score utilizing the model provided was 40.1%. Patients with multiple comorbidities at risk for decreased long-term survival can be identified with our model, which is more applicable for high-volume contemporary institutions.
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Affiliation(s)
- Albeir Y Mousa
- Department of Surgery, Robert C. Byrd Health Sciences Center, West Virginia University, Vascular Center of Excellence, Charleston Area Medical Center, Charleston, WV, USA
| | - Joseph Bozzay
- Center for Health Services and Outcomes Research, Charleston Area Medical Center Health Education and Research Institute, Charleston, WV, USA
| | - Mike Broce
- Center for Health Services and Outcomes Research, Charleston Area Medical Center Health Education and Research Institute, Charleston, WV, USA
| | - Michael Yacoub
- Department of Surgery, Robert C. Byrd Health Sciences Center, West Virginia University, Vascular Center of Excellence, Charleston Area Medical Center, Charleston, WV, USA
| | - Patrick A Stone
- Department of Surgery, Robert C. Byrd Health Sciences Center, West Virginia University, Vascular Center of Excellence, Charleston Area Medical Center, Charleston, WV, USA
| | - Aravinda Najundappa
- Department of Surgery, Robert C. Byrd Health Sciences Center, West Virginia University, Vascular Center of Excellence, Charleston Area Medical Center, Charleston, WV, USA
| | - Mark C Bates
- Department of Surgery, Robert C. Byrd Health Sciences Center, West Virginia University, Vascular Center of Excellence, Charleston Area Medical Center, Charleston, WV, USA
| | - Ali F AbuRahma
- Department of Surgery, Robert C. Byrd Health Sciences Center, West Virginia University, Vascular Center of Excellence, Charleston Area Medical Center, Charleston, WV, USA
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Kolh P, De Hert S, De Rango P. The Concept of Risk Assessment and Being Unfit for Surgery. Eur J Vasc Endovasc Surg 2016; 51:857-66. [PMID: 27053098 DOI: 10.1016/j.ejvs.2016.02.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Accepted: 02/03/2016] [Indexed: 02/06/2023]
Abstract
The concept of risk assessment and the identification of surgical unfitness for vascular intervention is a particularly controversial issue today as the minimally invasive surgical population has increased not only in volume but also in complexity (comorbidity profile) and age, requiring an improved pre-operative selection and definition of high risk. A practical step by step (three steps, two points for each) approach for surgical risk assessment is suggested in this review. As a general rule, the identification of a "high risk" patient for vascular surgery follows a step by step process where the risk is clearly defined, quantified (when too "high"?), and thereby stratified based on the procedure, the patient, and the hospital, with the aid of predictive risk scores. However, there is no standardized, updated, and objective definition for surgical unfitness today. The major gap in the current literature on the definition of high risk in vascular patients explains the lack of sound validated predictive systems and limited generalizability of risk scores in vascular surgery. In addition, the concept of fitness is an evolving tool and many traditional high risk criteria and definitions are no longer valid. Given the preventive purpose of most vascular procedures performed in elderly asymptomatic patients, the decision to pursue or withhold surgery requires realistic estimates not only regarding individual peri-operative mortality, but also life expectancy, healthcare priorities, and the patient's primary goals, such as prolongation of life versus maintenance of independence or symptom relief. The overall "frailty" and geriatric risk burden, such as cognitive, functional, social, and nutritional status, are variables that should be also included in the analyses for stratification of surgical risk in elderly vascular patients.
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Affiliation(s)
- P Kolh
- Cardiovascular Surgery Department, University Hospital (CHU, ULg) of Liège, Belgium.
| | - S De Hert
- Department of Anesthesiology, Ghent University Hospital, Ghent University, Ghent, Belgium
| | - P De Rango
- Unit of Vascular Surgery, Hospital S.M. Misericordia, Perugia, Italy
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Lim S, Halandras PM, Park T, Lee Y, Crisostomo P, Hershberger R, Aulivola B, Cho JS. Outcomes of endovascular abdominal aortic aneurysm repair in high-risk patients. J Vasc Surg 2015; 61:862-8. [DOI: 10.1016/j.jvs.2014.11.081] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Accepted: 11/25/2014] [Indexed: 11/24/2022]
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Kauffmann C, Douane F, Therasse E, Lessard S, Elkouri S, Gilbert P, Beaudoin N, Pfister M, Blair JF, Soulez G. Source of Errors and Accuracy of a Two-Dimensional/Three-Dimensional Fusion Road Map for Endovascular Aneurysm Repair of Abdominal Aortic Aneurysm. J Vasc Interv Radiol 2015; 26:544-51. [DOI: 10.1016/j.jvir.2014.12.019] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Revised: 12/09/2014] [Accepted: 12/11/2014] [Indexed: 10/23/2022] Open
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Gloviczki P, Huang Y, Oderich GS, Duncan AA, Kalra M, Fleming MD, Harmsen WS, Bower TC. Clinical presentation, comorbidities, and age but not female gender predict survival after endovascular repair of abdominal aortic aneurysm. J Vasc Surg 2015; 61:853-61.e2. [DOI: 10.1016/j.jvs.2014.12.004] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2014] [Accepted: 12/03/2014] [Indexed: 12/20/2022]
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Open versus Endovascular Repair of Abdominal Aortic Aneurysm in the Elective and Emergent Setting in a Pooled Population of 37,781 Patients: A Systematic Review and Meta-Analysis. ISRN CARDIOLOGY 2014; 2014:149243. [PMID: 25006502 PMCID: PMC4004021 DOI: 10.1155/2014/149243] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Accepted: 02/03/2014] [Indexed: 01/09/2023]
Abstract
Background. We evaluated the incidence of mortality and myocardial infarction (MI) in endovascular repair (EVAR) as compared to open aneurysm repair (OAR) in both elective and ruptured abdominal aortic aneurysm (AAA ) setting. Methods. We analyzed the rates of 30-day mortality, 30-day MI, and hospital length of stay (LOS) based on comparative observation and randomized control trials involving EVAR and OAR. Results. 41 trials compared EVAR to OAR with a total pooled population of 37,781 patients. Analysis of elective and ruptured AAA repair favored EVAR with respect to 30-day mortality with a pooled odds ratio of 0.19 (95% CI 0.17–0.20; I2 = 88.9%; P < 0.001). There were a total of 1,835 30-day MI events reported in the EVAR group as compared to 2,483 events in the OAR group. The pooled odds ratio for elective AAA was 0.74 (95% CI 0.58–0.96; P = 0.02) in favor of EVAR. The average LOS was reduced by 296.75 hrs (95% CI 156.68–436.82 hrs; P < 0.001) in the EVAR population. Conclusions. EVAR has lower rates of 30-day mortality, 30-day MI, and LOS in both elective and ruptured AAA repair.
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Open Conversion After Endovascular Aortic Aneurysm Repair: A Single-Center Experience. Ann Vasc Surg 2013; 27:856-64. [DOI: 10.1016/j.avsg.2012.06.031] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2012] [Revised: 05/10/2012] [Accepted: 06/14/2012] [Indexed: 11/21/2022]
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Qadura M, Pervaiz F, Harlock JA, Al-Azzoni A, Farrokhyar F, Kahnamoui K, Szalay DA, Rapanos T. Mortality and reintervention following elective abdominal aortic aneurysm repair. J Vasc Surg 2013; 57:1676-83, 1683.e1. [PMID: 23719040 DOI: 10.1016/j.jvs.2013.02.013] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2012] [Revised: 01/29/2013] [Accepted: 02/02/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND The objective of this study is to provide an up-to-date meta-analysis on the short- and long-term mortality rates of elective repair of abdominal aortic aneurysms (AAAs) via the open and endovascular approaches. METHODS MEDLINE, EMBASE, and Cochrane Central Register of Controlled trials, conference proceeding from major vascular meetings were searched for randomized trials comparing open vs elective endovascular aneurysm repair (EVAR) of AAAs. A random-effects model was used for analysis. Risk ratio (RR) and 95% confidence intervals (CIs) of open vs EVAR were calculated for short- and long-term mortality and reintervention rates. RESULTS The analysis encompassed four randomized controlled trials with a total of 2783 patients. The open repair group resulted in significantly increased 30-day postoperative all-cause mortality compared with EVAR repair group (3.2% vs 1.2%; RR, 2.81; 95% CI, 1.60-4.94); however, there is no statistical difference in the long-term all-cause mortality between both groups (RR, 0.97; 95% CI, 0.86-1.10). Interestingly, fewer patients underwent reintervention procedures in the open repair group compared with those who had EVAR repair (9.3% vs 18.9%; RR, 0.49; 95% CI, 0.40-0.60), but this finding is doubtful due to the large heterogeneity. Lastly, no statistical difference in long-term mortality rates attributable to cardiovascular disease (CVD), aneurysm related, or stroke were found between the two types of repair. CONCLUSIONS Results of this meta-analysis demonstrate that the 30-day all-cause mortality rate is higher with open than with EVAR repair; however, there is no statistical difference in the long-term all-cause and cause-specific mortality between both groups. The reintervention rate attributable to procedural complication was higher in the EVAR group. Because of the equivalency of long-term outcomes and the short-term benefits of EVAR, an endovascular-first approach to AAAs can be supported by the meta-analysis.
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Affiliation(s)
- Mohammad Qadura
- Division of Vascular Surgery, McMaster University, Hamilton, Ontario, Canada
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Awab A, Elahmadi B, Lamkinsi T, El Moussaoui R, El Hijri A, Azzouzi A, Alilou M. [Epidemiology and risk factors for major respiratory complications after aortic surgery]. Pan Afr Med J 2013; 14:13. [PMID: 23504435 PMCID: PMC3597864 DOI: 10.11604/pamj.2013.14.13.1853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2012] [Accepted: 12/17/2012] [Indexed: 11/24/2022] Open
Abstract
Introduction L'incidence des complications respiratoires postopératoires (CRPO) reste très diversement appréciées selon les critères diagnostiques retenues dans les différentes études, ce qui la fait varier de 5 à plus de 50%. Les CRPO majeurs après chirurgie de l'aorte abdominale sont responsables d'une grande morbi-mortalité pouvant aller jusqu’à 36%, d'une durée d'hospitalisation et d'un coût plus importants. Ainsi dans l'optique d'améliorer notre prise en charge périopératoire de la chirurgie de l'aorte, nous avons décidé de mener une étude pour dresser le profil épidémiologique et déterminer les facteurs de risque des complications respiratoires dans notre contexte Méthodes Il s'agit d'une étude de cohorte rétrospective du mois de Janvier 2007 au mois de décembre 2011 portant sur l'ensemble des patients opérés pour pathologie aortique au bloc opératoire central de l'hôpital Ibn Sina de Rabat, Maroc. Résultats Cent vingt cinq patients ont été inclus dans notre étude, 24 patients ont été opérés pour anévrysme de l'aorte abdominale et 101 patients pour lésion occlusive aortoiliaque. Dans notre série 22 malades soit 17,6% ont présenté une complication respiratoire majeure avec, une reventilation dans 4,8% des cas, une difficulté de sevrage de la ventilation artificielle dans 3,2% des cas, une pneumopathie dans 4% des cas, un syndrome de détresse respiratoire aigue (SDRA) dans 4% des cas et une nécessité de fibroaspiration bronchique dans 1,6% des cas. En analyse univariée: l’âge, la présence d'une BPCO avec dyspnée stade 3 ou 4, la présence d'une anomalie à l'EFR préopératoire, la présence d'un stade avancé (III ou IV) de LOAI et la reprise chirurgicale étaient statistiquement associés à la survenue d'une complication respiratoire postopératoire. En analyse multivariée, seule une anomalie à l'EFR en préopératoire constituait un facteur de risque indépendant de survenue d'une complication respiratoire postopératoire dans notre série avec un Odds Ratio (OR): 11,5; un Intervalle de Confiance (IC) à 95% de (1,6 - 85,2) et un p = 0,016. Conclusion Au terme de notre étude, il nous parait donc nécessaire pour diminuer l'incidence des CRPO majeurs dans notre population, d'agir sur les facteurs que nous jugeons modifiables tel l'amélioration de l’état respiratoire basal moyennant une préparation respiratoire préopératoire, s'intégrant dans un véritable programme de réhabilitation et associant une rééducation à l'effort, une kinésithérapie incitative ainsi qu'une optimisation des thérapeutiques habituelles.
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Affiliation(s)
- Almahdi Awab
- Université Mohammed V, unité de pédagogie et de recherche en anesthésie réanimation, CHU Ibn Sina, Rabat, Morocco
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McBride EL, Paap C, Murray-Krezan C, Goff JM. Long-term follow-up of endovascular abdominal aortic aneurysm repair in a rural veteran patient population. Am J Surg 2012; 204:e39-43. [PMID: 23022249 DOI: 10.1016/j.amjsurg.2012.07.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2012] [Revised: 07/13/2012] [Accepted: 07/18/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND The endovascular repair of abdominal aortic aneurysms (EVARs) requires follow-up to detect and treat late complications. METHODS Two hundred eleven patients underwent EVAR for infrarenal, nonruptured abdominal aortic aneurysms from 1999 to 2010 at the Raymond G. Murphy VA Medical Center, Albuquerque, NM. A retrospective review examined patient demographics, comorbidities, the distance the patient lived from the facility, early and late complications, and the device implanted. Statistical analysis included the chi-square test for independence, the Fisher exact test, and the 2-sample Mann-Whitney U test for means. RESULTS The mean time from the operation to the first complication was 21 months (standard deviation = 20 months) with a mean follow-up of 48 months (standard deviation = 36 months). The late complication rate was 22.8% (54 patients). Sixteen percent did not require any reinterventions, 57% were treated with percutaneous interventions, and 27% required an open surgical procedure. No single comorbidity, combination of comorbidities, distance the patient lived from the facility, or device implanted was predictive of complications. CONCLUSIONS EVAR follow-up is essential to detect complications. When complications occur, the majority occur well after the initial treatment, and most can be treated with minimally invasive percutaneous techniques.
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Affiliation(s)
- Erica L McBride
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
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Greenberg JI, Dorsey C, Dalman RL, Lee JT, Harris E, Hernandez-Boussard T, Mell MW. Long-term results after accessory renal artery coverage during endovascular aortic aneurysm repair. J Vasc Surg 2012; 56:291-6; discussion 296-7. [DOI: 10.1016/j.jvs.2012.01.049] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2011] [Revised: 01/13/2012] [Accepted: 01/14/2012] [Indexed: 11/16/2022]
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Ballard DJ, Filardo G, Graca BD, Powell JT. Clinical practice change requires more than comparative effectiveness evidence: abdominal aortic aneurysm management in the USA. J Comp Eff Res 2012; 1:31-44. [DOI: 10.2217/cer.11.6] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Adoption of healthcare innovations frequently outpaces the evidence of effectiveness. Endovascular repair (EVAR) for abdominal aortic aneurysms in the USA demonstrates how comparative effectiveness research without evidence-based reimbursement changes may fail to influence clinical practice. Randomized controlled trials for small abdominal aortic aneurysms demonstrate no lasting benefits of EVAR or open surgical repair (OSR) compared with surveillance, and for large abdominal aortic aneurysms demonstrate no lasting survival benefit of EVAR over OSR, and do show poorer durability and higher costs for EVAR. Nonetheless, >50% of elective abdominal aortic aneurysm repairs in the USA use EVAR. Factors that may be driving the high use of EVAR include patient preference, surgeons’ desire to appear ‘up-to-date’ in the procedures they offer, higher hourly surgeon reimbursement for EVAR than OSR, and the expansion of physician specialties able to perform abdominal aortic aneurysm repair from only vascular surgeons with OSR, to vascular surgeons and interventional radiologists/cardiologists with EVAR. By comparison, in Canada, where government health insurance restricts EVAR coverage to high surgical risk patients, only approximately 25% of abdominal aortic aneurysm repairs are performed using EVAR. Country-specific cost studies and a prospective population-based study collecting detailed clinical data to identify patient subgroups that truly benefit from a particular management strategy are needed to inform policy regarding EVAR availability and reimbursement.
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Affiliation(s)
| | - Giovanni Filardo
- Institute for Health Care Research & Improvement, Baylor Health Care System, 8080 North Central Expressway, Suite 500, Dallas, TX 75206, USA
- Department of Statistical Science, Southern Methodist University, Dallas, TX, USA
- Department of Infectious Diseases, University of Louisville, Louisville, KY, USA
| | - Briget da Graca
- Institute for Health Care Research & Improvement, Baylor Health Care System, 8080 North Central Expressway, Suite 500, Dallas, TX 75206, USA
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Regarding "effect of gender on long-term survival after abdominal aortic aneurysm repair based on results from the Medicare national database". J Vasc Surg 2011; 54:1553-4; author reply 1554-5. [PMID: 22027444 DOI: 10.1016/j.jvs.2011.05.119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2011] [Revised: 05/03/2011] [Accepted: 05/07/2011] [Indexed: 11/21/2022]
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Abstract
As health-care reforms progress, quality and risk assessment in the health-care system of the USA surface as critical issues. This review considers past, present and possible future changes in quality assessment along with formal programs of complication reduction and pay for performance (PFP) as related to surgery and vascular interventions. Strategies for quality improvement include aggregate and risk-adjusted outcome measurement, process compliance with the Surgical Complication Improvement Program, oversight and PFP, now policies of the Centers for Medicare and Medicaid Services (CMS). Advantages, disadvantages and unintended consequences of these policies are discussed. While ongoing system changes will influence vascular surgical practice, unique opportunities and obligations exist for vascular surgeons to contribute to quality assessment of their interventions, to evaluate long-term outcomes and to devise strategies for comprehensive cost-effective care for the conditions affecting patients with vascular disease.
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Sultan S, Hynes N. Clinical Efficacy and Cost per Quality-Adjusted Life Years of Pararenal Endovascular Aortic Aneurysm Repair Compared With Open Surgical Repair. J Endovasc Ther 2011; 18:181-96. [DOI: 10.1583/10-3072.1] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Schermerhorn ML, Giles KA, Sachs T, Bensley RP, O'Malley AJ, Cotterill P, Landon BE. Defining perioperative mortality after open and endovascular aortic aneurysm repair in the US Medicare population. J Am Coll Surg 2011; 212:349-55. [PMID: 21296011 DOI: 10.1016/j.jamcollsurg.2010.12.003] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2010] [Revised: 12/06/2010] [Accepted: 12/06/2010] [Indexed: 11/28/2022]
Abstract
BACKGROUND Perioperative mortality is reported after abdominal aortic aneurysm (AAA) repair, but there is no agreed upon standard definition. Often, 30-day mortality is reported because in-hospital mortality may be biased in favor of endovascular repair given the shorter length of stay. However, the duration of increased risk of death after aneurysm repair is unknown. STUDY DESIGN We used propensity score modeling to create matched cohorts of US Medicare beneficiaries undergoing endovascular (n = 22,830) and open (n = 22,830) AAA repair from 2001 to 2004. We calculated perioperative mortality using several definitions including in-hospital, 30-day, and combined 30-day and in-hospital mortality. We determined the relative risk (RR) of death after open compared with endovascular repair as well as the absolute mortality difference. To define the duration of increased risk we calculated biweekly interval death rates for 12 months. RESULTS In-hospital, 30-day, and combined 30-day and in-hospital mortality for open and endovascular repair were 4.6% versus 1.1%, 4.8% versus 1.6%, and 5.3% versus 1.7%, respectively. The absolute differences in mortality were similar, at 3.5%, 3.2%, and 3.7%. The RRs of death (95% confidence interval) were 4.2 (3.6 to 4.8), 3.1 (2.7 to 3.4), and 3.2 (2.8 to 3.5). Biweekly interval death rates were highest during the first month after endovascular repair (0.6%) and during the first 2.5 months (0.5% to 2.1%) after open repair. After 2.5 months, rates were similar for both repairs (<0.5%) and stabilized after 3 months. The 90-day mortality rates for open and endovascular repair were 7.0% and 3.2%, respectively. CONCLUSIONS In-hospital mortality comparisons overestimate the benefit of endovascular repair compared with 30-day or combined 30-day and in-hospital mortality. The total mortality impact of AAA repair is not realized until 3 months after repair and the duration of highest mortality risk extends longer for open repair.
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Affiliation(s)
- Marc L Schermerhorn
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA.
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Moll FL, Powell JT, Fraedrich G, Verzini F, Haulon S, Waltham M, van Herwaarden JA, Holt PJE, van Keulen JW, Rantner B, Schlösser FJV, Setacci F, Ricco JB. Management of abdominal aortic aneurysms clinical practice guidelines of the European society for vascular surgery. Eur J Vasc Endovasc Surg 2011; 41 Suppl 1:S1-S58. [PMID: 21215940 DOI: 10.1016/j.ejvs.2010.09.011] [Citation(s) in RCA: 996] [Impact Index Per Article: 76.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2010] [Accepted: 09/12/2010] [Indexed: 12/11/2022]
Affiliation(s)
- F L Moll
- Department of Vascular Surgery, University Medical Center Utrecht, The Netherlands.
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Ploeg AJ, Flu HC, Lardenoye JHP, Hamming JF, Breslau PJ. Assessing the quality of surgical care in vascular surgery; moving from outcome towards structural and process measures. Eur J Vasc Endovasc Surg 2011; 40:696-707. [PMID: 20889355 DOI: 10.1016/j.ejvs.2010.05.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2009] [Accepted: 05/08/2010] [Indexed: 11/30/2022]
Abstract
OBJECTIVES This study presents a review of studies reporting on quality of care in vascular surgery. The aim of this study was to provide insight in quality improvement initiatives in vascular surgery. DESIGN Original data were collected from MEDLINE and EMBASE databases. Inclusion criteria were: description of one of the three factors of quality of care, e.g. process, outcome or structure and prospectively described. All articles identified were ascribed to a domain of quality of care. RESULTS 57 prospective articles were included, drawn from 859 eligible reports. Structure as an indicator of quality of care was described in 19 reports, process in 7 reports and outcome in 31 reports. Most studies based on structural measures considered the introduction of a clinical pathway or a registration system. Reports based on process measures showed promising results. Outcome as clinical indicator mainly focussed on identifying risk factors for morbidity, mortality or failure of treatment. CONCLUSIONS Structure and process indicators are evaluated scarcely in vascular surgery. Many studies in vascular surgery have been focussed on outcomes as indicator of quality of care, but a shift towards process measures should be considered as focus of attention in the future.
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Affiliation(s)
- A J Ploeg
- Leiden University Medical Center (LUMC), Department of Vascular Surgery, Albinusdreef 2, PO Box 9600, 2300 RC Leiden, The Netherlands.
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Traub NL, Brooks RB. GI Disease. Perioper Med (Lond) 2011. [DOI: 10.1007/978-0-85729-498-2_27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Hsieh NC, Hung LP, Shih CC, Keh HC, Chan CH. Intelligent Postoperative Morbidity Prediction of Heart Disease Using Artificial Intelligence Techniques. J Med Syst 2010; 36:1809-20. [DOI: 10.1007/s10916-010-9640-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2010] [Accepted: 12/08/2010] [Indexed: 10/18/2022]
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Chung J, Corriere MA, Milner R, Kasirajan K, Salam A, Dodson TF, Chaikof EL, Veeraswamy RK. Midterm results of adjunctive neck therapies performed during elective infrarenal aortic aneurysm repair. J Vasc Surg 2010; 52:1435-41. [DOI: 10.1016/j.jvs.2010.06.163] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2010] [Revised: 06/07/2010] [Accepted: 06/21/2010] [Indexed: 11/24/2022]
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Post-Endovascular Aneurysm Repair Patient Outcomes and Follow-Up Are Not Adversely Impacted by Long Travel Distance to Tertiary Vascular Surgery Centers. Ann Vasc Surg 2010; 24:1075-81. [DOI: 10.1016/j.avsg.2010.05.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2009] [Revised: 03/30/2010] [Accepted: 05/16/2010] [Indexed: 11/17/2022]
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Endovascular aneurysm repair in nonagenarians is safe and effective. J Vasc Surg 2010; 52:1140-6. [DOI: 10.1016/j.jvs.2010.06.076] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2010] [Revised: 06/08/2010] [Accepted: 06/14/2010] [Indexed: 11/18/2022]
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Inherent problems with randomized clinical trials with observational/no treatment arms. J Vasc Surg 2010; 52:237-41. [PMID: 20620768 DOI: 10.1016/j.jvs.2010.02.255] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2009] [Revised: 02/18/2010] [Accepted: 02/18/2010] [Indexed: 11/21/2022]
Abstract
Randomized clinical trials (RCTs) offering an observation/no treatment (OBS/NoRx) arm as control and which are focused on the management of a condition with potentially life-threatening consequences, however small the risk, often experience a significant rate of crossover to treatment by those randomized to the OBS/NoRx arm. Results of these trials when analyzed on intent-to-treat basis often fail to resolve the issue at which they were directed. The authors have observed this in trials of abdominal aortic aneurysms with this design and use these to exemplify the dilemmas RCTs of such design create, with crossovers ranging from 27% to over 60% (EVAR II, UKSAT, ADAM, PIVOTAL). Results of these trials are frequently used as level I medical evidence and their potential impact on clinical decision making and reimbursement can be quite significant and long-lasting. Recommendations regarding trial end points and suggestions to mitigate the high crossover effect are offered. It may be that some clinical conditions dealing with potentially life-threatening problems should not be studied in randomized prospective clinical trials containing an OBS/NoRx arm.
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Albuquerque FC, Tonnessen BH, Noll RE, Cires G, Kim JK, Sternbergh WC. Paradigm shifts in the treatment of abdominal aortic aneurysm: Trends in 721 patients between 1996 and 2008. J Vasc Surg 2010; 51:1348-52; discussion 1352-3. [DOI: 10.1016/j.jvs.2010.01.078] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2009] [Revised: 01/12/2010] [Accepted: 01/25/2010] [Indexed: 11/25/2022]
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Jim J, Sanchez LA. Abdominal Aortic Aneurysms: Endovascular Repair. ACTA ACUST UNITED AC 2010; 77:238-49. [DOI: 10.1002/msj.20180] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Ng TT, Mirocha J, Magner D, Gewertz BL. Variations in the utilization of endovascular aneurysm repair reflect population risk factors and disease prevalence. J Vasc Surg 2010; 51:801-9, 809.e1. [DOI: 10.1016/j.jvs.2009.10.115] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2009] [Revised: 10/21/2009] [Accepted: 10/22/2009] [Indexed: 11/28/2022]
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Mendonça CT, de Carvalho CA, Weingärtner J, Shiomi AY, de Melo Costa DS. Endovascular Treatment of Abdominal Aortic Aneurysms in High-Surgical-Risk Patients Using Commercially Available Stent-Grafts. J Endovasc Ther 2010; 17:89-94. [DOI: 10.1583/09-2872.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Bush RL, DePalma RG, Itani KMF, Henderson WG, Smith TS, Gunnar WP. Outcomes of care of abdominal aortic aneurysm in Veterans Health Administration facilities: results from the National Surgical Quality Improvement Program. Am J Surg 2010; 198:S41-8. [PMID: 19874934 DOI: 10.1016/j.amjsurg.2009.08.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2009] [Revised: 08/09/2009] [Accepted: 08/13/2009] [Indexed: 11/16/2022]
Abstract
This report describes outcomes of care for abdominal aortic aneurysms (AAAs), along with methods used by the Veterans Affairs (VA) National Surgical Quality Improvement Program (NSQIP) in tracking, monitoring, and improving surgical results in VA facilities. Since the inception of NSQIP in 1994, a continual drop in overall surgical mortality, along with decreased morbidity, has occurred. A parallel improvement in results of vascular surgery and AAA repair was also observed. Soon after introduction of endovascular aneurysm repair (EVAR), with Food and Drug Administration device approval in 1999, robust electronic NSQIP records immediately began to capture individual facility performances and outcomes for both types of AAA repair. The NSQIP data center provided actual and risk-adjusted analyses for both procedures semiannually. These analyses have been used by its executive board to provide recommendations, often based on site visits, to improve outcomes. Requirements for reporting of facility-specific data and feedback, paper audits, and site visits appear to relate directly to improved AAA care. Veterans Health Administration (VHA) outcomes of AAA repair are comparable to those reported nationally and internationally and have continued to improve in recent years. National VHA initiatives, based on data feedback and active oversight, relate to some of the lowest AAA mortality rates available. This review describes past, present, and possible future NSQIP strategies to improve outcomes for AAA repair with general comments about recent alternative proposals.
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Affiliation(s)
- Ruth L Bush
- Texas A&M Health Sciences Center, Olin E. Teague Veterans Affairs Medical Center, Temple, TX, USA.
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Chaikof EL, Brewster DC, Dalman RL, Makaroun MS, Illig KA, Sicard GA, Timaran CH, Upchurch GR, Veith FJ. The care of patients with an abdominal aortic aneurysm: the Society for Vascular Surgery practice guidelines. J Vasc Surg 2009; 50:S2-49. [PMID: 19786250 DOI: 10.1016/j.jvs.2009.07.002] [Citation(s) in RCA: 453] [Impact Index Per Article: 30.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2009] [Revised: 07/06/2009] [Accepted: 07/06/2009] [Indexed: 02/08/2023]
Affiliation(s)
- Elliot L Chaikof
- Department of Surgery, Emory University, Atlanta, Ga 30322, USA.
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Itani KM. Fifteen years of the National Surgical Quality Improvement Program in review. Am J Surg 2009; 198:S9-S18. [DOI: 10.1016/j.amjsurg.2009.08.003] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2009] [Accepted: 08/04/2009] [Indexed: 12/22/2022]
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Millon A, Deelchand A, Feugier P, Chevalier J, Favre J. Conversion to Open Repair after Endovascular Aneurysm Repair: Causes and Results. A French Multicentric Study. Eur J Vasc Endovasc Surg 2009; 38:429-34. [DOI: 10.1016/j.ejvs.2009.06.001] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2009] [Accepted: 06/02/2009] [Indexed: 10/20/2022]
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Mendonça CT, Moreira RCR, Carvalho CAD, Moreira BD, Weingärtner J, Shiomi AY. Endovascular treatment of abdominal aortic aneurysms in high-surgical-risk patients. J Vasc Bras 2009. [DOI: 10.1590/s1677-54492009000100009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background: Following the publication of a prospective randomized trial (Endovascular Aneurysm Repair Trial 2 - EVAR2) that questioned the benefits of endovascular repair of abdominal aortic aneurysms (AAA) in high-surgical-risk patients, we decided to analyze our initial and long-term results with endovascular AAA repair in this patient population. Objective: To evaluate the operative mortality, long-term survival, frequency of secondary operations, outcome of the aneurysm sac, primary and secondary patency rates, and rupture rate after aortic stent-graft placement in high-surgical-risk patients. Methods: From April 2002 to February 2008, 40 high-surgical and anesthetic risk patients with an AAA managed by a bifurcated aortic endograft were entered in a prospective registry. Data concerning diagnosis, operative risk, treatment and follow-up were analyzed in all patients Results: Twenty-four Excluder® and 16 Zenith® stent-grafts were successfully implanted. Thirty patients (75%) were classed ASA III and 10 (25%) were ASA IV. Mean aneurysm diameter was 64 mm. Operative mortality was 2.5%. Two patients required reintervention during the mean follow-up of 28.5 months. Survival rate at 3 years was 95%. There were four endoleaks, one case of endotension, and one endograft limb occlusion. Primary and secondary patency rates at 3 years were 97.5 and 100%, respectively. There were no ruptures. Conclusions: Initial and long-term results with endovascular treatment of AAA in high-surgical-risk patients were satisfactory, and appear to justify such approach for this patient population.
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Affiliation(s)
- Célio Teixeira Mendonça
- Universidade Positivo, Brazil; Universidade Federal do Paraná, Brazil; University of South Carolina, USA
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Shalhoub J, Naughton P, Lau N, Tsang JS, Kelly CJ, Leahy AL, Cheshire NJW, Darzi AW, Ziprin P. Concurrent colorectal malignancy and abdominal aortic aneurysm: a multicentre experience and review of the literature. Eur J Vasc Endovasc Surg 2009; 37:544-56. [PMID: 19233691 DOI: 10.1016/j.ejvs.2009.01.004] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2008] [Accepted: 01/14/2009] [Indexed: 10/21/2022]
Abstract
OBJECTIVES There is lack of consensus regarding concurrent vs. staged approaches, and the prioritisation of staged procedures in cases presenting with colorectal carcinoma (CRC) and abdominal aortic aneurysm (AAA) synchronously. We aim to present our experience, review the literature on this therapeutic dilemma and examine the role of endovascular aortic repair (EVAR). DESIGN, MATERIALS AND METHODS An observational study of the experience of two centres and a systematic review of the published literature. RESULTS Twenty-four patients were identified from the prospective databases of two tertiary referral centres between 2001 and 2006. Intervention for both malignancy and aneurysm was performed in 13 patients. In 10 patients, cancer resection was performed initially and was followed by open aneurysm repair (n=3) or EVAR (n=7). Two patients (AAA diameters: 7.0 and 8.0cm) underwent EVAR prior to colonic resection. One patient was selected for synchronous surgery. There were no interval AAA ruptures, graft infection or postoperative mortalities. Literature review identified 269 such cases; of these 101 were treated by combined surgery. In staged surgery, there were nine interval aneurysmal ruptures and one aortic graft infection. CONCLUSIONS In our experience, staged management can be undertaken, without interval aneurysmal rupture. EVAR has an evolving role in preventing delay in CRC management, in high-risk patients, and during combined intervention.
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Affiliation(s)
- J Shalhoub
- Department of Bio Surgery & Surgical Technology, Faculty of Medicine, Imperial College London, St Mary's Hospital, London, UK
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Vetrhus M, Viddal B, Loose H, Neverdal N, Nordang E. Abdominale aortaaneurismer – endovaskulær og åpen kirurgi. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2009; 129:2248-51. [DOI: 10.4045/tidsskr.09.0091] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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García-Lizame M, Eliseo-Mussenden O, Peguero-Brínguez Y, Díaz-Hernández O, Santana-Porbén S. Influencia del estado nutricional en los resultados de la cirugía revascularizadora del sector aortoilíaco. ANGIOLOGIA 2009. [DOI: 10.1016/s0003-3170(09)16006-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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45
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Buth J. Invited commentary. J Vasc Surg 2008. [DOI: 10.1016/j.jvs.2008.07.068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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46
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Wahlgren CM, Malmstedt J. Outcomes of endovascular abdominal aortic aneurysm repair compared with open surgical repair in high-risk patients: Results from the Swedish Vascular Registry. J Vasc Surg 2008; 48:1382-8; discussion 1388-9. [DOI: 10.1016/j.jvs.2008.07.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2008] [Revised: 07/04/2008] [Accepted: 07/07/2008] [Indexed: 10/21/2022]
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Corbett TJ, Callanan A, Morris LG, Doyle BJ, Grace PA, Kavanagh EG, McGloughlin TM. A review of the in vivo and in vitro biomechanical behavior and performance of postoperative abdominal aortic aneurysms and implanted stent-grafts. J Endovasc Ther 2008; 15:468-84. [PMID: 18729555 DOI: 10.1583/08-2370.1] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
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.
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Affiliation(s)
- Timothy J Corbett
- Centre for Applied Biomedical Engineering Research, MSSI, Department of Mechanical and Aeronautical Engineering, University of Limerick, Ireland
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48
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Blochle R, Lall P, Cherr GS, Harris LM, Dryjski ML, Hsu HK, Dosluoglu HH. Management of patients with concomitant lung cancer and abdominal aortic aneurysm. Am J Surg 2008; 196:697-702. [PMID: 18823617 DOI: 10.1016/j.amjsurg.2008.07.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2008] [Revised: 07/02/2008] [Accepted: 07/02/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND Management of patients with an abdominal aortic aneurysm (AAA) and malignancy is challenging. We aimed to define the coincidence of AAA and lung cancer and to determine a treatment strategy. METHODS The outcomes for patients diagnosed with AAA and lung cancer between 1991 and 2004 at our institution were reviewed retrospectively. RESULTS We identified 75 patients with both lesions among 1,096 AAA and 1,875 lung cancer patients. Survival correlated with cancer stage; only 3 deaths were directly attributable to the patient's AAA. Of 59 patients who did not have AAA repair at the time of cancer diagnosis, 12 were repaired. Twenty-seven of those 59 patients had a 5.0-cm or larger AAA; only 1 patient with a 7.5-cm AAA had a rupture 5 months after thoracotomy and died. CONCLUSIONS The co-existence of AAA and lung cancer is not rare; prognosis is poor and largely determined by the lung cancer stage. Open or endovascular repair of AAA rarely is justified in patients with advanced disease unless the AAA is symptomatic or large (>7 cm). Treatment for AAAs greater than 5.5 cm should be based on stage, histology, and patient comorbidities.
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Affiliation(s)
- Raphael Blochle
- Department of Surgery, Division of Vascular Surgery, State University of New York at Buffalo, 3495 Bailey Ave., Buffalo, NY 14215, USA
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Alsac JM, Houbballah R, Francis F, Paraskevas N, Coppin T, Cerceau O, Castier Y, Leseche G. Impact of the introduction of endovascular aneurysm repair in high-risk patients on our practice of elective treatment of infrarenal abdominal aortic aneurysms. Ann Vasc Surg 2008; 22:829-33. [PMID: 18804949 DOI: 10.1016/j.avsg.2008.03.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2007] [Revised: 03/09/2008] [Accepted: 03/18/2008] [Indexed: 10/21/2022]
Abstract
The aim of this work was to evaluate, in terms of activity and immediate postoperative results, the modifications of our elective surgical treatment of infrarenal abdominal aortic aneurysms (AAAs) resulting from the use of stent grafts to treat AAAs, following the recommendations issued by the French Health Products Safety Agency (AFSSAPS) in December 2003. This monocentric and retrospective study used the clinical data of patients operated on for asymptomatic AAA between January 2001 and December 2006. Endovascular treatment of AAAs with aortic stent grafts was introduced in our current practice in January 2004, following the recommendations of the AFSSAPS (high-risk patients for open surgery presenting with an AAA > or =50 mm). Group I was composed of patients operated on between January 2001 and December 2003 according to the standard open technique. Group II was composed of patients operated on between January 2004 and December 2006 with either standard open surgery or endovascular surgery. The main criteria of evaluation were the number of operated patients, their American Society of Anesthesiology (ASA) score of surgical risk, and the intrahospital morbidity and mortality. The number of treated patients significantly increased between these two periods (group I n = 49, group II n = 88, with 38 endovascular treatments; p < 0.001), without any changes in average age (70 vs. 72 years), percentage of men (93.7% vs. 95.5%), and mean AAA size (57.8 vs. 56 mm) between the two groups. ASA scores were significantly higher in group II (ASA III and IV, group I = 20.4% vs. group II = 55.7%; p < 0.0001), whereas the intrahospital mortality rate (4.1% vs. 3.4%) and the rate of major postoperative complications (16.3% vs. 11%) have remained stable. In group II, the median duration of hospitalization was significantly reduced (12 vs. 9 days, p < 0.001). In conclusion, in our center, following the AFSSAPS recommendations, the introduction of endovascular treatment has enabled us to electively treat a greater number of AAA patients with higher surgical risk, without aggravating the immediate postoperative results.
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Affiliation(s)
- Jean-Marc Alsac
- Service de Chirurgie Vasculaire, Thoracique et Transplantation Pulmonaire, Bichat-Claude Bernard University Hospital, Paris, France.
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Rutherford RB. Management of Abdominal Aortic Aneurysms: Which Risk Factors Play a Role in Decision-Making? Semin Vasc Surg 2008; 21:124-31. [DOI: 10.1053/j.semvascsurg.2008.05.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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