Contemporary results of open repair of ruptured abdominal aortoiliac aneurysms: Effect of surgeon volume on mortality

[Recommendations for the specialist further training of nursing personnel on intensive care units in the treatment of abdominal aortic aneurysms: results of a modified Delphi procedure with experts]

INTRODUCTION

The medical development in the previous 15 years and the changes in treatment reality of the comprehensive elective treatment of abdominal aortic aneurysms necessitate a re-evaluation of the quality assurance guidelines of the Federal Joint Committee in Germany (QBAA-RL). In the current version this requires a specialist further training quota for nursing personnel in intensive care wards of 50%. The quota was determined in 2008 based on expert opinions, although a direct empirical evidence base for this does not exist.

METHODS

Representatives from the fields of patient representation, physicians, nursing personnel and other relevant interface areas were invited to participate in a modified Delphi procedure. Following a comprehensive narrative literature search, a survey and focus group discussions with national and international experts, a total of three anonymized online-based voting rounds were carried out for which previously determined key statements were assessed with a 4‑point Likert scale (totally disagree up to totally agree). In addition, the expert panel had also defined a recommendation for a minimum quota for the specialist training of nursing personnel on intensive care wards in the treatment of abdominal aortic aneurysms, whereby an a priori agreement of 80% of the participants was defined as the consensus limit.

RESULTS

Overall, 37 experts participated in the discussions and three successive voting rounds (participation rate 89%). The panel confirmed the necessity of a re-evaluation of the guideline recommendations and recommended the introduction of a shift-related minimum quota of 30% of the full-time equivalent of nursing personnel on intensive care wards and the introduction of structured promotional programs for long-term elevation of the quota.

CONCLUSION

In this national Delphi procedure with medical and nursing experts as well as representatives of patients, the fundamental benefits and needs of professional specialist qualifications in the field of intensive care medicine were confirmed. The corresponding minimum quota for specialist further training of intensive care nursing personnel should generally apply without limitations to specific groups. The expert panel stipulates a shift-related minimum quota for intensive care nursing personnel with specialist training of 30% of the nursing personnel on intensive care wards and the obligatory introduction of structured and transparent promotion programs for the long-term enhancement.

Impact of Interfacility Transfer of Ruptured Abdominal Aortic Aneurysm Patients

OBJECTIVES

Interfacility transfer (IT) of patients with ruptured (r) abdominal aortic aneurysm (AAA) occurs not infrequently for a higher level of care. This study evaluates using contemporary administrative database the impact of IT on mortality after rAAA repair.

METHODS

Healthcare Cost and Utilization Project Database for NY (2016) and NJ/MD/FL (2016-2017) were queried using ICD-10^th edition to identify patients who underwent open and endovascular repair of AAA. Hospitals were categorized into quartiles (Q) per overall volume. Mortality rates of IT vs non-transferred (NT) rAAA patients per treatment modality (open [rOAR] vs. endovascular [rEVAR]) were compared. Cox proportional hazard model was used to estimate hazard ratios (HR) for mortality.

RESULTS

1475 patients presented with rAAA of whom 672 (45.6%) were not treated. Of the remaining 803 patients, 226 (28.1%) were transferred; 50 (22.1%) died without a repair after IT. The remaining 752 patients (176 IT + 576 NT) underwent 491 rEVARs and 261 rOARs. Baseline characteristics were similar between IT and NT patients except for higher proportion of Blacks (P=.03), lower-income families (P=.049) and rOAR (45.5% vs 31.4%, p=.001) in IT patients. Overall mortality rates were similar between NT (30.2%) and IT (27.3%, P=.46). On sub-group analysis, operative mortality rates after rEVAR were similar between NT and IT patients, without differences among hospital quartiles. After rOAR, however, operative mortality rates were lower in IT patients, largely due to improved outcomes in Q4 hospitals (P=.001, Q4 vs Q1, 2 & 3). Cox regression analysis demonstrated age (HR 1.03, CI 1.00-1.06, P=.02) and low-volume hospitals (Q1-3) (HR 1.89, CI 1.02-3.51, P=.04) are predictors of mortality. Total charges were similar ($286,727 IT vs $265,717 NT, P=.38).

CONCLUSIONS

Less than 30% of rAAA patients deemed to be a candidate for repair are transferred. IT does not affect mortality rates after rEVAR, irrespective of hospital volume. For rOAR candidates, however, regionalization of care with prompt transfer to a high-volume center improves the survival benefits without increased health care cost.

Association between individual surgeon volume and outcome in mitral valve surgery: a systematic review

Background

Surgeon volume has been identified as a possible factor that influences outcomes in mitral valve (MV) surgery. The aim of this study was to systematically review all published studies on the association between individual surgeon volume and outcome in MV surgery.

Methods

PubMed was searched last on 19 November 2020. The reporting of this systematic review was done in accordance with PRISMA guidelines. Manuscripts were eligible when these studied individual surgeon volumes and its association with repair rate, mortality or reoperation. The methodological quality of the studies was assessed with the Newcastle-Ottawa Scale (NOS). Absolute numbers and percentages of the outcome measures, odds ratios (ORs), P values and threshold values regarding surgeon volume were collected.

Results

A total of 7 retrospective cohort studies were included in the qualitative analysis with total of 158488 patients. Definitions of surgeon volumes were found to be heterogenic and therefore pooling of data was not possible. Surgeon volume was significantly associated with repair rate (OR =1.25–5.5) and mortality (OR =0.46–0.84 and OR =1.50–2.27 depending on the reference group). Regarding reoperation, results were not consistent and did not always show a significant lower reoperation rate when surgeon volume increased. A mean threshold of minimally 30 MV surgeries per year was found.

Discussion

Higher surgeon volume is significantly associated with improved outcomes of repair rate and mortality. MV should preferentially be performed by high-volume surgeons and centralization of MV surgery might be necessary.

The Relationship Between Operative Volume and Peri-operative Mortality After Non-elective Aortic Aneurysm Repair in Australia

OBJECTIVE

Hospital and surgeon operative caseload is thought to be associated with peri-operative mortality following the non-elective repair of aortic aneurysms; however, whether such an association exists within the Australian healthcare setting is unknown.

METHODS

The Australasian Vascular Audit was interrogated to identify patients undergoing non-elective (emergency [EMG] or semi-urgent [URG]) aortic aneurysm repair between 2010 and 2016, as well as their treating surgeon and hospital. Hierarchal logistic regression modelling was used to assess the impact of caseload on outcomes after both endovascular (EVAR) and open surgical repair (OSR).

RESULTS

Volume counts were determined from 14 262 patients (4 121 OSR and 10 141 EVAR). After exclusion of elective procedures and duplicates, 1 153 EVAR (570 EMG and 583 URG) and 1 245 OSR (946 EMG and 299 URG) non-elective cases remained for the analysis. Crude mortality was 24.0% following OSR (EMG 29.2%; URG 7.7%) and 7.5% following EVAR (EMG 12.6%; URG 2.4%). Univariable analysis demonstrated an association between OSR mortality and hospital volume (quintile [Q] 1: 25.3%, Q2: 27.8%, Q3: 23.9%, Q4: 27.0%, Q5: 16.2%; p = .030), but not surgeon (Q1: 25.2%, Q2: 27.4%, Q3: 26.0%, Q4: 21.4%, Q5: 19.5%, p = .32). Multivariable analysis confirmed this association (odds ratio (OR) [95% CI]; Q1 vs 5: 1.91 [1.13-3.21], Q2 vs. 5: 2.01[1.24-3.25], Q3 vs. 5: 1.41 [0.86-2.29], Q4 vs. 5: 1.92 [1.17-3.15]; p = .020). The difference was most pronounced in the EMG OSR group [Q1 - 3 vs. 4-5] (OR 1.63 [1.07-2.48]; p = .020). Mortality after EVAR was not associated with either hospital (Q1: 6.3%, Q2: 10%, Q3: 6.8%, Q4: 4.5%, Q5: 10%; p = .14) or surgeon volume (Q1: 9.3%, Q2: 5.7%, Q3: 8.1%, Q4: 7.0%, Q5: 7.3%; p = .67).

CONCLUSION

There is an inverse correlation between hospital volume and peri-operative mortality following EMG open repair of aortic aneurysm. These data support restructuring Australian pathways of care to direct suspected ruptured aneurysm to institutions that reach a minimum volume threshold.

National temporal trends and determinants of cost of abdominal aortic aneurysm repair

INTRODUCTION

In recent decades, there has been a shift in the management of aortic abdominal aneurysm from open intervention (open aortic aneurysm repair) to an endovascular approach (endovascular aortic aneurysm repair). This shift has yielded clinical as well as socioeconomic reverberations. In our current study, we aim to analyze these effects brought about by the switch to endovascular treatment and to scrutinize the determinants of cost variations between the two treatment modalities.

METHODS

The National (Nationwide) Inpatient Sample database was queried for clinical data ranging from 2001 to 2013 using International Classification of Disease, 9th Revision (ICD-9) codes for open and endovascular aortic repair. Clinical parameters and financial data related to the two treatment modalities were analyzed. Temporal trends of index hospitalization costs were determined. Multivariate linear regression was used to characterize determinants of cost for endovascular aneurysm repair and open abdominal aortic aneurysm repair.

RESULTS

A total of 128,154 aortic repairs were captured in our analysis, including 62,871 open repairs and 65,283 endovascular repairs. Over the assessed time period, there has been a decrease in the cost of elective endovascular aortic aneurysm repair from $34,975.62 to $31,384.90, a $3,590.72 difference (p < 0.01), while the cost of open aortic repair has increased from $37,427.77 to $43,640.79 by 2013, a $6,212.79 increase (p < 0.01). The cost of open aortic aneurysm repair disproportionately increased at urban teaching hospitals, where by 2013, it costs $50,205.59, compared to $34,676.46 at urban nonteaching hospitals, and $34,696.97 at rural institutions. Urban teaching hospitals were found to perform an increasing proportion of complex open aneurysm repairs, involving concomitant renal and visceral bypass procedures. On multivariate analysis, strong determinants of cost increase for both endovascular aortic aneurysm repair and open aortic aneurysm repair are rupture status, prolonged length of stay, occurrence of complications, and the need for disposition to a nursing facility or another acute care institution.

CONCLUSION

As the vascular community has shifted from an open repair of abdominal aortic aneurysm to an endovascular approach, a number of unforeseen clinical and economic effects were noted. We have characterized these ramifications to help guide further clinical decision and resource allocation.

Perioperative, Postoperative, and Long-Term Outcomes Following Open Surgical Repair of Ruptured Abdominal Aortic Aneurysm

We investigated factors that affected perioperative, postoperative, and long-term outcomes of patients who underwent open emergency surgical repair of ruptured abdominal aortic aneurysms (RAAA). All patients who underwent open emergency surgical repair from 1990 to 2011 were included (463 patients; 374 [81%] male; mean age 74.7 ± 8.7years). Logistic and Cox regression analyses were performed to explore the association of variables with outcomes. Preoperatively, median (interquartile range) hemoglobin was 11.2 (9.5-12.8) g/dL, and median creatinine level was 140 (112-177) µmol/L. Intraoperatively, the median operative time was 2.25 (2-3) hours, and median estimated blood loss was 1.5 (0.5-3) L; 250 (54%) patients required intraoperative inotropes, and a median of 6 (4-8) units of blood was transfused. Median length of hospital stay was 11 (7-20) days. In-hospital mortality rate was 35.6%, and 5-year mortality was 48%. Age, distance traveled, operation duration, postoperative myocardial infarction (MI), and multi-organ failure (MOF) were predictors of in-hospital mortality and long-term outcome. Additionally, postoperative acute renal failure predicted in-hospital mortality. In patients with RAAA undergoing open surgical repair, the strongest predictors of in-hospital mortality and long-term outcome were postoperative MOF and MI and operative duration.

Open Surgery for Ruptured Abdominal Aortic Aneurysm - 38 Years Experience at an Academic Center in Chile

BACKGROUND

Few series of ruptured abdominal aortic aneurysm (RAAA) from Latin America have been published.

OBJECTIVES

To report the outcomes of RAAA treated with open surgical repair (OSR) in a University Hospital in Chile. Secondary objectives are the identification of prognostic factors and survival rates.

METHODS

Retrospective review of consecutive RAAA patients treated with OSR between September 1979 and December 2017. Medical records, diagnostic images, and follow-up details were obtained. Statistical methods include multiple logistic regression analysis.

RESULTS

One hundred and sixteen patients underwent OSR for RAAA. The average age was 72.3 years (54-95), 62.9% ≥ 70 years, and 81.9% male. Preoperative systolic pressure <90 mm Hg was present in 74 patients (63.8%), and 10 (8.6%) experienced cardiac arrest before surgery. Only 30.2% were known to have an AAA before rupture. The mean aortic diameter was 7.9 cm. Sixteen patients had juxtarenal aneurysms (13.8%). The rupture was intra or retroperitoneal in 111 cases (95.7%), there were 4 fistulas to neighboring veins and one into the duodenum. Reconstruction included tubular graft in 39.7% and bifurcated in 58.6%. The estimated mean blood loss was 3,456 ± 2,768 mL (median 3,000). Mean mechanical ventilation was 7.4 ± 12.0 days and hemodialysis requirement in 21.8%. Six patients died during surgery and other 24 during the first postoperative month or in hospital, for an overall mortality rate of 25.9%. Age ≥70 years (P < 0.01), blood pressure less than 90 mm Hg (P = 0.03) and dialysis (P < 0.01) were associated with higher 30-day mortality rates. The survival rate was 68.0, 65.3, 44.3, and 25.2% at 1, 2, 5, and 10 years, respectively.

CONCLUSIONS

EVAR for RAAA is not affordable in every country. Outcomes of open RAAA repair at our institution are similar to results reported recently for OSR by the USA and European Medical centers.

The Surgeon Volume-outcome Relationship: Not Yet Ready for Policy

OBJECTIVE

Increasing surgeon volume may improve outcomes for index operations. We hypothesized that there may be surrogate operative experiences that yield similar outcomes for surgeons with a low-volume experience with a specific index operation, such as esophagectomy.

BACKGROUND

The relationship between surgeon volume and outcomes has potential implications for credentialing of surgeons. Restrictions of privileges based on surgeon volume are only reasonable if there is no substitute for direct experience with the index operation. This study was aimed at determining whether there are valid surrogates for direct experience with a sample index operation-open esophagectomy.

METHODS

The Nationwide Inpatient Sample (2003-2009) was utilized. Surgeons were stratified into low and high-volume groups based on annual volume of esophagectomy. Surrogate volume was defined as the aggregate annual volume per surgeon of upper gastrointestinal operations including excision of esophageal diverticulum, gastrectomy, gastroduodenectomy, and repair of diaphragmatic hernia.

RESULTS

In all, 26,795 esophagectomies were performed nationwide (2003-2009), with a crude inhospital mortality rate of 5.2%. Inhospital mortality decreased with increasing volume of esophagectomies performed annually: 7.7% and 3.8% for low and high-volume surgeons, respectively (P < 0.0001). Among surgeons with a low-volume esophagectomy experience, increasing volume of surrogate operations improved the outcomes observed for esophagectomy: 9.7%, 7.1%, and 4.3% for low, medium, and high-surrogate-volume surgeons, respectively (P = 0.016).

CONCLUSIONS

Both operation-specific volume and surrogate volume are significant predictors of inhospital mortality for esophagectomy. Based on these observations, it would be premature to limit hospital privileges based solely on operation-specific surgeon volume criteria.

Endovascular management of ruptured abdominal aortic aneurysms and acute aortic dissections

The management of vascular emergencies is dependent on rapid identification and confirmation of the diagnosis with concurrent patient stabilization prior to immediate transfer to the operating suite. A variety of technological advances in diagnostic imaging as well as the advent of minimally invasive endovascular interventions have shifted the contemporary treatment algorithms of such pathologies. This review provides a comprehensive discussion on the current state and future trends in the management of ruptured abdominal aortic aneurysms as well as acute aortic dissections.

Systematic review and meta-analysis of the risk of bowel ischemia after ruptured abdominal aortic aneurysm repair

OBJECTIVE

Outcomes after repair of ruptured abdominal aortic aneurysm (RAAA) have improved in the last decade. It is unknown whether this has resulted in a reduction of postoperative bowel ischemia (BI). The primary objective was to determine BI prevalence after RAAA repair. Secondary objectives were to determine its major sequelae and differences between open repair (OR) and endovascular aneurysm repair (EVAR).

METHODS

This systematic review (PROSPERO CRD42017055920) followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Meta-analysis Of Observational Studies in Epidemiology (MOOSE) guidelines. MEDLINE and Embase were searched for studies published from 2005 until 2018. The methodologic quality of observational studies was assessed with the Methodological Index for Non-Randomized Studies (MINORS) tool. The quality of the randomized controlled trials (RCTs) was assessed with the Cochrane Collaboration's tool for assessing risk of bias. BI prevalence and rates of BI as cause of death, reoperation, and bowel resection were estimated with meta-analyses with a random-effects model. Differences between OR and EVAR were estimated with pooled risk ratios with 95% confidence intervals (CIs). Changes over time were assessed with Spearman rank test (ρ). Publication bias was assessed with a funnel plot analysis.

RESULTS

A total of 101 studies with 52,670 patients were included; 72 studies were retrospective cohort studies, 14 studies were prospective cohort studies, 12 studies were retrospective administrative database studies, and 3 studies were RCTs. The overall methodologic quality of the RCTs was high, but that of observational studies was low. The pooled prevalence of BI ranged from of 0.08 (95% CI, 0.07-0.09) in database studies to 0.10 (95% CI, 0.08-0.12) in cohort studies. The risk of BI was higher after OR than after EVAR (risk ratio, 1.79; 95% CI, 1.25-2.57). The pooled rate of BI as cause of death was 0.04 (95% CI, 0.03-0.05), and that of BI as cause of reoperation and bowel resection ranged between 0.05 and 0.07. BI prevalence did not change over time (ρ, -0.01; P = .93). The funnel plot analysis was highly suggestive of publication bias.

CONCLUSIONS

The prevalence of clinically relevant BI after RAAA repair is approximately 10%. Approximately 5% of patients undergoing RAAA repair suffer from severe consequences of BI. BI is less prevalent after EVAR than after OR.

Randomized clinical trial of remote ischaemic preconditioning versus no preconditioning in the prevention of perioperative myocardial infarction during open surgery for ruptured abdominal aortic aneurysm

Background

Remote ischaemic preconditioning (RIPC) has been suggested as a means of protecting vital organs from reperfusion injury during major vascular surgery. This study was designed to determine whether RIPC could reduce the incidence of perioperative myocardial infarction (MI) during open surgery for ruptured abdominal aortic aneurysm (AAA). Secondary aims were to see if RIPC could reduce 30-day mortality, multiple organ failure, acute intestinal ischaemia, acute kidney injury and ischaemic stroke.

Methods

This randomized, non-blinded clinical trial was undertaken at three vascular surgery centres in Denmark. Patients who had open surgery for ruptured AAA were randomized to intervention with RIPC or control in a 1 : 1 ratio. Postoperative complications and deaths were registered, and ECG and blood samples were obtained daily during the hospital stay.

Results

Of 200 patients randomized, 142 (72 RIPC, 70 controls) were included. There was no difference in rates of perioperative MI between the RIPC and control groups (36 versus 43 per cent respectively), or in rates of organ failure. However, in the per-protocol analysis 30-day mortality was significantly reduced in the RIPC group (odds ratio 0·46, 95 per cent c.i. 0·22 to 0·99; P = 0·048).

Conclusion

RIPC did not reduce the incidence of perioperative MI in patients undergoing open surgery for ruptured AAA. Registration number: NCT00883363 ( http://www.clinicaltrials.gov).

Analysis of in hospital mortality and long-term survival excluding in hospital mortality after open surgical repair of ruptured abdominal aortic aneurysm

Purpose

The aim of this study was to confirm the factors that affect the mortality associated with the open surgical repair of ruptured abdominal aortic aneurysm (rAAA) and to analyze the long-term survival rates.

Methods

A retrospective review was performed on a prospectively collected database that included 455 consecutive patients who underwent open surgical repair for AAA between January 2001 and December 2012. We divided our analysis into in-hospital and postdischarge periods and analyzed the risk factors that affected the long-term survival of rAAA patients.

Results

Of the 455 patients who were initially screened, 103 were rAAA patients, and 352 were non-rAAA (nAAA) patients. In the rAAA group, 25 patients (24.2%) died in the hospital and 78 were discharged. Long-term survival was significantly better in the nAAA group (P = 0.001). The 2-, 5-, and 10-year survival rates of the rAAA patients were 87%, 73.4%, and 54.1%, respectively. Age (hazard ratio [HR], 1.05; 95% confidence interval [CI], 1.02–.08; P < 0.001) and aneurysm rupture (HR, 1.96; 95% CI, 1.12–.44; P = 0.01) significantly affected long-term survival.

Conclusion

Preoperative circulatory failure is the most common cause of death for in-hospital mortality of rAAA patients. After excluding patients who have died during the perioperative period, age is the only factor that affects the survival of rAAA patients.

A ruptured abdominal aortic aneurysm that requires preoperative cardiopulmonary resuscitation is not necessarily lethal

OBJECTIVE

A ruptured abdominal aortic aneurysm (RAAA) is associated with a high mortality rate. If cardiopulmonary resuscitation (CPR) is required before surgical repair, mortality rates are said to approach 100%. The aim of this multicenter, retrospective study was to study outcome in RAAA patients who required CPR before a surgical (endovascular or open) repair (CPR group). RAAA patients who did not need CPR served as controls (non-CPR group).

METHODS

Over a 5-year time period, demographic and clinical characteristics and specifics of preoperative CPR if necessary were studied in all patients who were treated for a RAAA in three large, nonacademic hospitals.

RESULTS

A total of 199 consecutive RAAA patients were available for analysis; 176 patients were surgically treated. Thirteen of these 176 patients (7.4%) needed CPR, and 163 (92.6%) did not. A 38.5% (5 of 13) survival rate was observed in the CPR group. Thirty-day mortality was almost three times greater in the CPR group compared with the non-CPR group (61.5% vs 22.7%; P = .005). Both CPR patients who received endovascular aortic repair survived. In contrast, survival in 11 CPR patients who underwent open RAAA repair was 27% (3 of 11; P = .128). A trend for higher Hardman index was found in patients who received CPR compared with patients who did not receive CPR (P = .052). The 30-day mortality in patients with a 0, 1, 2, or 3 Hardman index was 16.1%, 31.0%, 37.9%, and 33.3%, respectively (P = .093).

CONCLUSIONS

An RAAA that requires preoperative CPR is not necessarily a lethal combination. Patient selection must be tailored before surgery is denied.

Can experience improve hospital management?

BACKGROUND

Experience curve effects were first observed in the industrial arena as demonstrations of the relationship between experience and efficiency. These relationships were largely determined by improvements in management efficiency and quality of care. In the health care industry, volume-outcome relationships have been established with respect to quality of care improvement, but little is known about the effects of experience on management efficiency. Here, we examine the relationship between experience and hospital management in Japanese hospitals.

METHODS

The study sample comprised individuals who had undergone surgery for unruptured abdominal aortic aneurysms and had been discharged from participant hospitals between April 1, 2006 and December 31, 2008. We analyzed the association between case volume (both at the hospital and surgeon level) and postoperative complications using multilevel logistic regression analysis. Multilevel log-linear regression analyses were performed to investigate the associations between case volume and length of stay (LOS) before and after surgery.

RESULTS

We analyzed 909 patients and 849 patients using the hospital-level and surgeon-level analytical models, respectively. The odds ratio of postoperative complication occurrence for an increase of one surgery annually was 0.981 (P < 0.001) at the hospital level and 0.982 (P < 0.001) at the surgeon level. The log-linear regression analyses showed that shorter postoperative LOS was significantly associated with high hospital-level case volume (coefficient for an increase of one surgery: -0.006, P = 0.009) and surgeon-level case volume (coefficient for an increase of one surgery: -0.011, P = 0.022). Although an increase of one surgery annually at the hospital level was statistically associated with a reduction of preoperative LOS by 1.1% (P = 0.006), there was no significant association detected between surgeon-level case volume and preoperative LOS (P = 0.504).

CONCLUSION

Experience at the hospital level may contribute to the improvement of hospital management efficiency.

Endovascular repair of ruptured abdominal aortic aneurysm does not confer survival benefits over open repair

OBJECTIVE

Endovascular repair of ruptured abdominal aortic aneurysm (rAAA) is being increasingly performed despite lack of good evidence for its superiority. Other reported studies suffer from patient selection and publication bias with limited follow-up. This study is a single-center propensity score comparing early and midterm outcomes between open surgical repair (OSR) and endovascular repair of rAAA (REVAR).

METHODS

A retrospective review from January 2001 to November 2010 identified 312 patients who underwent rAAA repairs. Thirty-one patients with antecedent AAA repair and three with incomplete records were excluded, leaving 37 REVARs and 241 OSRs. Propensity score-based matching for sex, age, preoperative hemodynamic status, surgeon's annual AAA volume, and preoperative cardiopulmonary resuscitation was performed in a 1:3 ratio to compare outcomes. Thirty-seven REVARs were matched with 111 OSRs. Late survival was estimated by Kaplan-Meier methods.

RESULTS

Operative time and blood replacement were higher with OSR. Overall complication rates were similar (54% REVAR vs 66% OSR; P = .23), except for higher incidences of tracheostomies (21% vs 3%; P = .015), myocardial infarction (38% vs 18%; P = .036), and acute tubular necrosis (47% vs 21%; P = .009) with OSR. Operative mortality rates were similar (22% REVAR vs 32% OSR), with an odds ratio of 0.63 for REVAR (95% confidence interval = [0.24, 1.48]; P = .40). No differences in the incidences for secondary interventions for aneurysm- or graft-related complications were noted (22% REVAR vs 22% OSR; P = .99). Kaplan-Meier estimates of 1-, 2-, and 3-year survival rates were also similar (50%, 50%, 42% REVAR vs 54%, 52%, 47% OSR; P = .66).

CONCLUSIONS

REVAR for rAAA does not seem to conclusively confer either acute or late survival advantages. Routine use of REVAR should be deferred until prospective, randomized trial data become available.

Defining the type of surgeon volume that influences the outcomes for open abdominal aortic aneurysm repair

OBJECTIVE

Prior studies have reported improved clinical outcomes with higher surgeon volume, which is assumed to be a product of the surgeon's experience with the index operation. We hypothesized that composite surgeon volume is an important determinant of outcome. We tested this hypothesis by comparing the impact of operation-specific surgeon volume versus composite surgeon volume on surgical outcomes, using open abdominal aortic aneurysm (AAA) repair as the index operation.

METHODS

The Nationwide Inpatient Sample was analyzed to identify patients undergoing open AAA repairs for 2000 to 2008. Surgeons were stratified into deciles based on annual volume of open AAA repairs ("operation-specific volume") and overall volume of open vascular operations ("composite volume"). Composite volume was defined by the sum of several open vascular operations: carotid endarterectomy, aortobifemoral bypass, femoral-popliteal bypass, and femoral-tibial bypass. Multiple logistic regression analyses were used to examine the relationship between surgeon volume and in-hospital mortality for open AAA repair, adjusting for both patient and hospital characteristics.

RESULTS

Between 2000 and 2008, an estimated 111,533 (95% confidence interval [CI], 102,296-121,232) elective open AAA repairs were performed nationwide by 6,857 surgeons. The crude in-hospital mortality rate over the study period was 6.1% (95% CI, 5.6%-6.5%). The mean number of open AAA repairs performed annually was 2.4 operations per surgeon. The mean composite volume was 5.3 operations annually. As expected, in-hospital mortality for open AAA repair decreased with increasing volume of open AAA repairs performed by a surgeon. Mortality rates for the lowest and highest deciles of surgeon volume were 10.2% and 4.5%, respectively (P < .0001). A similar pattern was observed for composite surgeon volume, as the mortality rates for the lowest and highest deciles of composite volume were 9.8% and 4.8%, respectively (P < .0001). After adjusting for patient and hospital characteristics, increasing composite surgeon volume remained a significant predictor of lower in-hospital mortality for open AAA repair (odds ratio, 0.994; 95% CI, .992-.996; P < .0001), whereas increasing volume of AAA repairs per surgeon did not predict in-hospital deaths.

CONCLUSIONS

The current study suggests that composite surgeon volume-not operation-specific volume-is a key determinant of in-hospital mortality for open AAA repair. This finding needs to be considered for future credentialing of surgeons.

Open surgery in endovascular aneurysm repair era: simplified classification in two risk groups owing to factors affecting mortality in 137 ruptured abdominal aortic aneurysms (RAAAs)

Our objective is to identify in 137 true RAAAs operated consecutively in open surgery: (1) diagnostic therapeutic aspects capable of influencing results, (2) risk classes with different prognosis, (3) any situations where the prognosis is so negative that surgery is not recommended. The relationship of 16 anamnestic, clinical and technical parameters prospectively collected with 30-day mortality was retrospectively evaluated by uni- and multivariate analyses. Thirty-day mortality was 37%. The univariate analysis identified as mortality predictors Hb ≤ 8 g/dl and circulatory shock at hospitalisation, but following the multivariate analysis only circulatory shock was a certainly significant risk-factor. The cumulative effect on mortality of the two parameters identified at univariate analysis translates into a statistically significant difference in mortality between two groups of patients: A (no or just one risk-factor) and B (two risk-factors). To reinstate euvolemia, rather than adequate haemoglobin values, improves the chances of success. A simple prognostic index into two risk classes is feasible, but abstention from surgery is not justified in any type of patient.

Systematic review and meta-analysis of the relationship between hospital volume and outcome for lower limb arterial surgery

Background

The aim was to investigate whether a relationship existed between case volume and outcome for lower limb vascular surgical procedures.

Methods

PubMed, Embase, the Cochrane Library and Google Scholar were searched for all articles on population-based studies on the volume–outcome relationship for lower limb vascular surgery at hospital level. Outcomes were mortality and subsequent amputation after lower limb vascular surgery. The data were subjected to meta-analysis by outcome.

Results

Some 452 093 patients from ten studies were included in the systematic review and five studies were included in meta-analyses. Seven of these articles found a significant positive hospital–volume outcome relationship. The pooled effect estimate for mortality was odds ratio (OR) 0·81 (95 per cent confidence interval 0·71 to 0·91) and that for amputation was OR 0·88 (0·79 to 0·98), with better results being found after surgery at higher-volume hospitals. Significant heterogeneity was seen in the data.

Conclusion

Higher-volume hospitals were associated with reduced amputation and mortality rates after lower limb vascular surgery. These data were not as conclusive as those for other vascular surgical procedures owing to significant heterogeneity.

Effect of early plasma transfusion on mortality in patients with ruptured abdominal aortic aneurysm

BACKGROUND

The ratio of red blood cell (PRBC) transfusion to plasma (FFP) transfusion (PRBC:FFP ratio) has been shown to impact survival in trauma patients with massive hemorrhage. The purpose of this study was to determine the effect of the PRBC:FFP ratio on mortality for patients with massive hemorrhage after ruptured abdominal aortic aneurysm (RAAA).

METHODS

A retrospective review was performed of patients undergoing emergent open RAAA repair from January 1987 to December 2007. Patients with massive hemorrhage (≥10 units of blood products transfused prior to conclusion of the operation) were included. The effects of patient demographics, admission vital signs, laboratory values, peri-operative variables, amount of blood products transfused, and the PRBC:FFP ratio on 30-day mortality were analyzed by multivariate analysis.

RESULTS

One hundred and twenty-eight of the 168 (76%) patients undergoing repair for RAAA received at least 10 units of blood products within the peri-operative period. Mean age was 73.1 ± 9.1 years, and 109 (85%) were men. Thirty-day mortality was 22.6% (29/128), including 11 intra-operative deaths. By multivariate analysis, 30-day mortality was markedly lower (15% vs 39%; P < .03) for patients transfused at a PRBC:FFP ratio ≤2:1 (HIGH FFP group) compared with those transfused at a ratio of >2:1 (LOW FFP), and the likelihood of death was more than 4-fold greater in the LOW FFP group (odds ratio 4.23; 95% confidence interval, 1.2-14.49). Patients in the HIGH FFP group had a significantly lower incidence of colon ischemia than those in the LOW FFP group (22.4% vs 41.1%; P = .004).

CONCLUSION

For RAAA patients requiring massive transfusion, more equivalent transfusion of PRBC to FFP (HIGH FFP) was independently associated with lower 30-day mortality. The lower incidence of colonic ischemia in the HIGH FFP group may suggest an additional benefit of early plasma transfusion that could translate into further mortality reduction. Analysis from this study suggests the potential feasibility for a more standardized protocol of initial resuscitation for these patients, and prospective studies are warranted to determine the optimum PRBC:FFP ratio in RAAA patients.

Endovascular repair of a ruptured abdominal aortic aneurysm in a patient with unfavorable anatomy

Endovascular repair of an abdominal aortic aneurysm (AAA) offers hope of improved outcomes in patients presenting with acute rupture. However, a high proportion of such patients have unfavorable proximal neck anatomy and are not suitable for treatment with conventional endografts. In this case report, the authors describe a successful endovascular repair of a ruptured AAA with very short and angulated proximal neck.

The future of EVAR in the management of ruptured AAAs

Endovascular repair of ruptured abdominal aortic aneurysms is an evolving technique. Data from nonrandomized series suggest that it may be beneficial in selected patients. In the next few years, a number of large randomized clinical trials will clarify its role. Issues regarding anatomical suitability, techniques, perioperative care, and service provision need to be addressed in order to optimize outcomes.

Vacuum-Pack Temporary Abdominal Wound Management with Delayed-Closure for the Management of Ruptured Abdominal Aortic Aneurysm and Other Abdominal Vascular Catastrophes: Absence of Graft Infection in Long Term Survivors

Patients who undergo open repair of ruptured abdominal aortic aneurysms (rAAA) may require delayed abdominal wound closure to prevent the adverse consequences of intra-abdominal hypertension and abdominal compartment syndrome. However, surgeons may be reticent to use delayed abdominal closure techniques due to concern that such management may increase the risk of graft infection. We retrospectively reviewed our patient experience with rAAA and other vascular catastrophes in which vacuum-pack abdominal wound management with delayed closure was used between 2000 and 2007. Eighteen of 23 patients treated with delayed closure survived (78%). In five early deaths, graft infection was not clinically suspected. Sixteen of 20 rAAA patients survived, with abdominal wound closure achieved at a mean of 4 days. Mean follow up was 53 months, the longest among comparable series. Graft infection has not been encountered in this group. Our results suggest that the potential risk of graft infection should not outweigh the benefits of vacuum-pack temporary abdominal wound management with delayed closure in critically ill patients at high risk for intra-abdominal hypertension and abdominal compartment syndrome after major abdominal vascular procedures.

Impact of hospital teaching status on survival from ruptured abdominal aortic aneurysm repair

OBJECTIVES

Controversy exists over the optimal hospital type to which high-risk surgical patients should be referred for operative management. While high volume centers have been traditionally advocated, recent evidence suggests teaching hospitals may have better outcomes for high-risk patients. We investigated whether mortality outcomes of patients undergoing surgery for ruptured abdominal aortic aneurysm (rAAA) were different between teaching hospitals and non-teaching hospitals, independent of hospital operative volume.

METHODS

A retrospective review of the Nationwide Inpatient Sample dataset (1998-2004) was performed to identify open and endovascular (EVAR) repair for rAAA. Hospitals were stratified by teaching status, including teaching hospitals (TH) with any type of residency training program, those with general surgery training programs (GSTH) and those with vascular surgery training programs (VSTH). The association of hospital teaching status with in-hospital mortality for open AAA repair and EVAR was assessed via multi-level multivariable logistic regression, controlling for patient demographics, comorbidities, and hospital operative volume.

RESULTS

Of 6636 open AAA repairs for rAAA, the overall perioperative mortality was 42%. Mortality was significantly lower at TH than non-TH (39.3% vs 44.5%; P < .05). Mortality was also lower at GSTH (38.7%) and VSTH (34.3%). After adjusting for hospital operative volume, patient demographics, and comorbidities, we found a 25% decrease in likelihood of in-hospital death at VSTH vs non-VSTH (odds ratio 0.75; 95% confidence interval 0.60-0.94; P < .05).

CONCLUSION

In-hospital mortality is significantly reduced for patients undergoing open AAA repair for rAAA at teaching hospitals and hospitals with vascular surgery training programs, independent of volume. These results suggest that in addition to factors associated with teaching hospitals in general, the type of specialty training within teaching institutions is a critical factor which may influence outcomes, specifically for patients with rAAA.

Has the Implementation of EVAR for Ruptured AAA Improved Outcomes?

Objective: Previous studies have demonstrated improved outcomes with Endovascular Aneurysm Repair (EVAR) for the treatment of ruptured abdominal aortic aneurysms (rAAA). However, these data may not be generalizable to all regions.

Methods: Retrospective cohort study (2001-2005) using state inpatient data.

Results: 5,176 patients underwent repair of AAA. 700 repairs were performed for rAAA (618 [88%] with open surgery (OS) and 82 [12%] with EVAR). Mortality for rAAA was similar for EVAR and OS (45.1% vs. 52.4%, P = 0.21). Lack of insurance (OR = 5.1; 95%CI: 1.7-15.2) was a predictor of mortality. Cost of repair for rAAA was greater for EVAR ($51,339 ± 51,719 vs. $39,967 ± 43,354, P = 0.03) and hospital LOS was similar (14.08 ± 17.97 vs.13.42 ± 18.18; P = 0.8). Conclusion: EVAR did not offer a survival benefit in the state, had a similar hospital LOS, and was significantly more expensive. Further evaluation exploring explanations for inferior outcomes by region are required as EVAR becomes more commonly implemented for rAAA.

Improving quality of care by system change

Change based on evidence

Model for the reconfiguration of specialized vascular services

Background

This article built on previous work to develop an algorithm for elective abdominal aortic aneurysm (AAA) repair and carotid endarterectomy (CEA), with the aim of improving patient survival by regionalization of services. Vascular procedures were used as an example of specialized surgical services.

Methods

A model was generated based on a national data set that incorporated the statistical demonstration of procedural safety, hospital annual surgical case volume, and travel distance and time. Elective AAA repair was used to construct a hub-and-spoke model that was tested against CEA. The impact of the model was quantified in terms of mortality rates, and travel distance and time.

Results

Only 48 vascular hubs were required to provide adequate coverage in England, with the majority of patients travelling for less than 1 h to access inpatient vascular surgery. The model predicted a reduction in the number of deaths from elective surgery for AAA (P &lt; 0·001) and CEA (P = 0·016).

Conclusion

Adoption of this strategic model may lead to improved outcome after AAA and CEA. It could be used as a model for the regionalization of specialized surgery. The model does not take into account the complexity of providing a comprehensive vascular service in every locality.