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Ramkumar N, Suckow BD, Columbo JA, Arya S, Sedrakyan A, Mackenzie TA, Brown JR, Goodney PP. Sex differences in outcomes among adults undergoing abdominal aortic aneurysm repair. J Vasc Surg 2023; 78:1212-1220.e5. [PMID: 37442215 DOI: 10.1016/j.jvs.2023.06.105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 06/28/2023] [Accepted: 06/30/2023] [Indexed: 07/15/2023]
Abstract
OBJECTIVE Although the differences in short-term outcomes between male and female patients in abdominal aortic aneurysm (AAA) repair have been well studied, it remains unclear if these sex disparities extend to other long-term adverse outcomes after AAA repair, such as reintervention and late rupture. METHODS We performed a retrospective cohort study of 13,007 patients who underwent either endovascular (EVAR) or open AAA repair (OAR) between 2003 and 2015 using data from the Vascular Quality Initiative registries. Eligible patients were linked to fee-for-service Medicare claims to identify late outcomes of rupture and aneurysm-specific reintervention. RESULTS The mean age of our cohort was 76 ± 6.7 years, 22% were female, 94% were White, and 77% underwent EVAR. The 10-year rupture incidence was slightly higher for women at 4.8 per 1000 person-years, vs 3.9 for men, but this difference was not statistically significant after risk adjustment (hazard ratio [HR] = 1.13, 95% confidence interval [CI]: 0.74-1.73). Likewise, we found no sex difference in reintervention rates (5.1 vs 4.8 in women per 1000 person-years) even after risk adjustment (HR = 0.95, 95% CI: 0.83-1.09). Regression models suggest effect modification by repair type for reintervention, where women who underwent index EVAR had a higher risk of reintervention than men (HR = 1.08, 95% CI: 0.93-1.26), whereas women who underwent OAR were at a lower risk of reintervention than men (HR = 0.79, 95% CI: 0.58-1.08); however, neither effect reached statistical significance within each subgroup. In addition, we found that the risk of reintervention for women vs men varied by clinical presentation, where women were less likely to undergo reintervention after an elective or symptomatic AAA repair but were more likely to undergo reintervention after a repair for AAA rupture (HR = 1.70, 95% CI: 1.05-2.75). CONCLUSIONS Male and female patients who underwent AAA repair had similar rates of reintervention and late aneurysm rupture in the 10 years after their procedure. However, our findings suggest that repair type and clinical presentation may affect the role of sex in clinical outcomes and warrant further exploration in these subgroups.
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Affiliation(s)
| | - Bjoern D Suckow
- Section of Vascular Surgery, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Jesse A Columbo
- Geisel School of Medicine, Hanover, NH; Section of Vascular Surgery, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Shipra Arya
- Department of Surgery, Stanford University Medical Center, Stanford, CA
| | | | - Todd A Mackenzie
- Geisel School of Medicine, Hanover, NH; Department of Biomedical Data Science, Geisel School of Medicine, Hanover, NH
| | - Jeremiah R Brown
- Department of Biomedical Data Science, Geisel School of Medicine, Hanover, NH; Department of Epidemiology, Geisel School of Medicine, Hanover, NH
| | - Philip P Goodney
- Geisel School of Medicine, Hanover, NH; Section of Vascular Surgery, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
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Locham S, Rodriguez A, Ford B, Glocker R, Ellis J, Mix D, Doyle A, Stoner M. Gender Differences in Aortic Anatomic Severity Grade and Long-Term Survival Following Elective Abdominal Aortic Aneurysm Repair at a Single Tertiary Center. Ann Vasc Surg 2022; 92:222-230. [PMID: 36572094 DOI: 10.1016/j.avsg.2022.12.083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 12/19/2022] [Accepted: 12/20/2022] [Indexed: 12/25/2022]
Abstract
BACKGROUND Anatomic severity grade (ASG) score is utilized to assess preoperative abdominal aortic aneurysms (AAA) and provide a quantitative data on its anatomic complexity. The aim of this study is to determine the anatomical differences and long-term survival between male and female patients undergoing elective AAA repair. METHODS All patients undergoing intact AAA repair from 2007 to 2014 were included. ASG scores were calculated based on preoperative anatomical characteristics including aortic neck, aneurysm, and iliac artery. Standard univariate analysis was used to evaluate patient and anatomical characteristics. Kaplan-Meier survival curves were used to evaluate long-term survival at 1 and 5 years. RESULTS A total of 379 patients were identified, of which, majority of them were males (80%). Females were on average 3 years older (mean [SD]: 74.32 [8.63] vs. 71.92 [8.64] years) and were more likely to undergo open repair (29.7% vs. 17.5%) (both P < 0.05). Both groups had similar comorbidities. The mean long-term follow-up (S.D.) was 6.21 (3.81) years. No significant difference was seen between males versus females in long-term survival at both 1 year (86.3% vs. 92.8, P = 0.06) and 5 year (68.5% vs. 72.7%, P = 0.38). In regard to the anatomical characteristics, females had shorter aortic neck length (mean in mm [S.D.]: 17.67 [1.41] vs. 27.20 [15.76]), increased tortuosity index [mean (S.D.): 1.11 (0.07) vs. 1.09 (0.07)]) and higher calcification [mean % (S.D.): 17.12 (21.17) vs. 10.59 (16.82)] (All P < 0.05). In contrast, males had larger aortic neck (mean in mm (S.D.): 23.81 (4.17) vs. 22.41 (4.16)] and iliac artery [mean in mm (S.D.): 7.70 (1.91) vs. 6.28 (1.67)] diameter (both P < 0.05). The mean total ASG score was significantly higher among females versus males [mean (S.D.): 17.23 (4.01) vs. 15.67 (3.96), P = 0.003]. After stratifying by ASG score ≥15, females had significantly lower survival at 1 year compared to males (82.6% vs. 92.1%, P = 0.04). However, this difference disappeared at 5 years. CONCLUSIONS The data demonstrate that females present at an older age with more complex AAA anatomy than males. Based on anatomical complexities, females were more likely to undergo open repair, with a corresponding increase in 1-year mortality, but not at 5 year. The data suggest that care processes for optimization of aortic surgery in females are needed to improve 1-year survival.
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Affiliation(s)
- Satinderjit Locham
- Division of Vascular Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY; University of Rochester School of Medicine & Dentistry, Rochester, NY
| | - Alejandra Rodriguez
- Division of Vascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Benjamin Ford
- Division of Vascular Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY; University of Rochester School of Medicine & Dentistry, Rochester, NY
| | - Roan Glocker
- Division of Vascular Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY; University of Rochester School of Medicine & Dentistry, Rochester, NY
| | - Jennifer Ellis
- Division of Vascular Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY; University of Rochester School of Medicine & Dentistry, Rochester, NY
| | - Doran Mix
- Division of Vascular Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY; University of Rochester School of Medicine & Dentistry, Rochester, NY
| | - Adam Doyle
- Division of Vascular Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY; University of Rochester School of Medicine & Dentistry, Rochester, NY
| | - Michael Stoner
- Division of Vascular Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY; University of Rochester School of Medicine & Dentistry, Rochester, NY.
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Mangel T, Mastracci TM. Outcomes of endovascular repair of abdominal and thoracoabdominal aneurysms in women - A review. Semin Vasc Surg 2022; 35:334-340. [DOI: 10.1053/j.semvascsurg.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 06/30/2022] [Accepted: 07/20/2022] [Indexed: 11/11/2022]
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Corsi T, Ciaramella MA, Palte NK, Carlson JP, Rahimi SA, Beckerman WE. Female Sex Is Associated With Reintervention and Mortality Following Elective Endovascular Abdominal Aortic Aneurysm Repair. J Vasc Surg 2022; 76:1494-1501.e1. [PMID: 35705120 DOI: 10.1016/j.jvs.2022.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 04/15/2022] [Accepted: 05/01/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE While sex differences in endovascular abdominal aortic aneurysm repair (EVAR) outcomes are increasingly reported, but contributing factors remain without consensus. We investigated disparities in sex-specific outcomes following elective EVAR at our institution and evaluated factors that may predispose females to increased morbidity and mortality. METHODS A retrospective chart review of all patients undergoing elective EVAR from 2011 to 2020 at a suburban tertiary care center was performed. The primary outcomes were five-year survival and freedom from reintervention. Fisher's exact test, t-tests, and Kaplan-Meier analysis using the rank-log test investigated associations between sex and outcomes. A multivariable Cox proportional hazard model controlling for age and common comorbidities evaluated the effect of sex on survival and freedom from reintervention. RESULTS Two hundred and seventy-three patients underwent elective EVAR during the study period, including 68 (25%) females and 205 (75%) males. Females were older on average than males (76 years vs. 73 years, p= <0.01) and were more likely to have chronic obstructive pulmonary disease (COPD; 38% versus 23%, p=0.01), require home oxygen therapy (9% versus 2%, p=0.04) or dialysis preoperatively (4% versus 0%, p=0.02). Distribution of other common vascular comorbidities was similar between the sexes. Thirty-day readmission was greater in females than males (18% versus 8%, p=0.02). Females had significantly lower survival at five years (48% ± 7.9% versus 65% ± 4.3%, p<0.01) and significantly lower one-year (89% ± 4.1% for females vs. 94% ± 1.7% for males, p=0.01) and five-year freedom from reintervention (69% ± 8.9% versus 84% ± 3.3%, p=0.02). On multivariable analysis, female sex (hazard ratio [HR]: 1.8, 95% confidence interval [CI]: 1.1-2.9), congestive heart failure (HR: 2.2, 95% CI: 1.2-3.9) and age (HR: 1.1, 95% CI: 1.0-1.1) were associated with 5-year mortality. Female sex remained as the only variable with a statistically significant association with five-year reintervention (HR: 2.4, 95% CI: 1.1-4.9). CONCLUSIONS Female sex was associated with decreased five-year survival and increased one and five-year reintervention following elective EVAR. Data from our institution suggests factors beyond patient age and baseline health risk likely contribute to greater surgical morbidity and mortality for females following elective EVAR.
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Affiliation(s)
- Taylor Corsi
- Rutgers Robert Wood Johnson Medical School, Rutgers University, Piscataway, NJ
| | | | - Nadia K Palte
- Rutgers Robert Wood Johnson Medical School, Rutgers University, Piscataway, NJ
| | - John P Carlson
- Rutgers Robert Wood Johnson Medical School, Rutgers University, Piscataway, NJ
| | - Saum A Rahimi
- Division of Vascular Surgery and Endovascular Therapy, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ
| | - William E Beckerman
- Division of Vascular Surgery and Endovascular Therapy, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ.
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Cury M, Matielo M, Soares R, Melo B, Nakamura E, Godoy M, Sacilotto R. Late outcomes of elective endovascular abdominal aortic aneurysm repair in a tertiary low-volume hospital in Brazil. Ann Vasc Surg 2022; 87:437-445. [DOI: 10.1016/j.avsg.2022.05.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 05/01/2022] [Accepted: 05/10/2022] [Indexed: 11/01/2022]
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Li B, Eisenberg N, Witheford M, Lindsay TF, Forbes TL, Roche-Nagle G. Sex Differences in Outcomes Following Ruptured Abdominal Aortic Aneurysm Repair. JAMA Netw Open 2022; 5:e2211336. [PMID: 35536576 PMCID: PMC9092206 DOI: 10.1001/jamanetworkopen.2022.11336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
IMPORTANCE Sex differences in aortic surgery outcomes are commonly reported. However, data on ruptured abdominal aortic aneurysm (rAAA) repair outcomes in women vs men are limited. OBJECTIVE To assess differences in perioperative and long-term mortality following rAAA repair in women vs men. DESIGN, SETTING, AND PARTICIPANTS A multicenter, retrospective cohort study was conducted using the Vascular Quality Initiative database, which prospectively captures information on patients who undergo vascular surgery across 796 academic and community hospitals in North America. All patients who underwent endovascular or open rAAA repair between January 1, 2003, and December 31, 2019, were included. Outcomes were assessed up to January 1, 2020. EXPOSURES Patient sex. MAIN OUTCOMES AND MEASURES Demographic, clinical, and procedural characteristics were recorded, and differences between women vs men were assessed using independent t test and χ2 test. The primary outcomes were in-hospital and 8-year mortality. Associations between sex and outcomes were analyzed using univariable and multivariable logistic regression and Cox proportional hazards regression analysis. RESULTS A total of 1160 (21.9%) women and 4148 (78.1%) men underwent rAAA repair during the study period. There was a similar proportion of endovascular repairs in women and men (654 [56.4%] vs 2386 [57.5%]). Women were older (mean [SD] age, 75.8 [9.3] vs 71.7 [9.6] years), more likely to have chronic kidney disease (718 [61.9%] vs 2184 [52.7%]), and presented with ruptured aneurysms of smaller diameters (mean [SD] 68 [18.2] vs 78 [30.2] mm). In-hospital mortality was higher in women (34.4% vs 26.6%; odds ratio, 1.44; 95% CI, 1.25-1.66), which persisted after adjusting for demographic, clinical, and procedural characteristics (adjusted odds ratio, 1.36; 95% CI, 1.12-1.66; P = .002). Eight-year survival was lower in women (36.7% vs 49.5%; hazard ratio, 1.25; 95% CI, 1.04-1.50; P = .02), which persisted when stratified by endovascular and open repair. This survival difference existed in both the US and Canada. Variables associated with long-term mortality in women included older age and chronic kidney disease. CONCLUSIONS AND RELEVANCE Women who underwent rAAA repair had higher perioperative and 8-year mortality rates following both endovascular and open repair compared with men. Older age and higher rates of chronic kidney disease in women were associated with higher mortality rates. These findings suggest that future studies should assess the reasons for these disparities and whether opportunities exist to improve AAA care for women.
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Affiliation(s)
- Ben Li
- University Health Network, Peter Munk Cardiac Centre, Division of Vascular Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Naomi Eisenberg
- University Health Network, Peter Munk Cardiac Centre, Division of Vascular Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Miranda Witheford
- University Health Network, Peter Munk Cardiac Centre, Division of Vascular Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Thomas F. Lindsay
- University Health Network, Peter Munk Cardiac Centre, Division of Vascular Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Thomas L. Forbes
- University Health Network, Peter Munk Cardiac Centre, Division of Vascular Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Graham Roche-Nagle
- University Health Network, Peter Munk Cardiac Centre, Division of Vascular Surgery, University of Toronto, Toronto, Ontario, Canada
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Ho-Yan Lee M, Li PY, Li B, Shakespeare A, Samarasinghe Y, Feridooni T, Cuen-Ojeda C, Alshabanah L, Kishibe T, Al-Omran M. A systematic review and meta-analysis of sex- and gender-based differences in presentation severity and outcomes in adults undergoing major vascular surgery. J Vasc Surg 2022; 76:581-594.e25. [DOI: 10.1016/j.jvs.2022.02.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 02/24/2022] [Indexed: 11/25/2022]
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How Does Female Sex Affect Complex Endovascular Aortic Repair? A Single Centre Cohort Study. Eur J Vasc Endovasc Surg 2021; 62:849-856. [PMID: 34686454 DOI: 10.1016/j.ejvs.2021.08.034] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 08/03/2021] [Accepted: 08/26/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVE There is growing evidence of a female patient disadvantage in complex endovascular aortic repair using fenestrated and branched endografts (FB-EVAR) primarily related to peri-procedural events including ischaemic and access vessel complications. This study aimed to determine the impact of sex differences on treatment patterns, and in hospital outcomes in a single centre cohort. METHODS This was a retrospective cross sectional single centre cohort study of all consecutive FB-EVAR procedures provided to patients with asymptomatic pararenal and thoraco-abdominal aortic aneurysm (TAAA) between 1 January 2010 and 28 February 2021. Adjusted multivariable logistic regression models were developed using backward (Wald) elimination of variables to determine the independent impact of female sex on short term outcomes. RESULTS In total, 445 patients (24.3% females, median age 73.0 years, IQR 66, 78) were included. Female patients had a smaller aneurysm diameter, less frequent coronary artery disease (29.6% vs. 44.8%, p = .007) and history of myocardial infarction (2.8% vs. 15.4%, p < .001) when compared with males. Females were more frequently treated for TAAA than males (49.1% vs. 25.2%, p < .001). The median length of post-procedural hospital stay was 10 days in females and 9 in males. In adjusted analyses, female sex was independently associated with higher mortality (odds ratio [OR] 10.135, 95% CI 2.264 - 45.369), post-procedural complications (OR 2.500, 95% CI 1.329 - 4.702), spinal cord ischaemia (OR 4.488, 95% CI 1.610 - 12.509), sepsis (OR 4.940, 95% CI 1.379 - 17.702), and acute respiratory insufficiency (OR 3.283, 95% CI 1.015 - 10.622) after pararenal aortic aneurysm repair during the hospital stay. CONCLUSION In this analysis of consecutively treated patients, female sex was associated with increased in hospital mortality, peri-procedural complications, and spinal cord ischaemia after elective complex endovascular repair of pararenal aortic aneurysm, while no differences were revealed in the TAAA subgroup. These results suggest that sex related patient selection and peri-procedural management should be studied in future research.
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Khoury MK, Thornton MA, Heid CA, Babb J, Ramanan B, Tsai S, Kirkwood ML, Timaran CH, Modrall JG. Endovascular Aortic Repair in Patients of Advanced Age. J Endovasc Ther 2021; 29:381-388. [PMID: 34622707 DOI: 10.1177/15266028211049342] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE Treatment decisions for the elderly with abdominal aortic aneurysms (AAAs) are challenging. With advancing age, the risk of endovascular aneurysm repair (EVAR) increases while life expectancy decreases, which may nullify the benefit of EVAR. The purpose of this study was to quantify the impact of EVAR on 1-year mortality in patients of advanced age. MATERIALS AND METHODS The 2003-2020 Vascular Quality Initiative Database was utilized to identify patients who underwent EVAR for AAAs. Patients were included if they were 80 years of age or older. Exclusions included non-elective surgery or missing aortic diameter data. Predicted 1-year mortality of untreated AAAs was calculated based on a validated comorbidity score that predicts 1-year mortality (Gagne Index, excluding the component associated with AAAs) plus the 1-year aneurysm-related mortality without repair. The primary outcome for the study was 1-year mortality. RESULTS A total of 11 829 patients met study criteria. The median age was 84 years [81, 86] with 9014 (76.2%) being male. Maximal AAA diameters were apportioned as follows: 39.6% were <5.5 cm, 28.6% were 5.5-5.9 cm, 21.3% were 6.0-6.9 cm, and 10.6% were ≥7.0 cm. The predicted 1-year mortality rate without EVAR was 11.9%, which was significantly higher than the actual 1-year mortality rate with EVAR (8.2%; p<0.001). The overall rate of perioperative MACE was 4.4% (n = 516). Patients with an aneurysm diameter <5.5cm had worse actual 1-year mortality rates with EVAR compared to predicted 1-year mortality rates without EVAR. In contrast, those with larger aneurysms (≥5.5cm) had better actual 1-year mortality rates with EVAR. The benefit from EVAR for those with Gagne Indices 2-5 was largely restricted to those with AAAs ≥ 7.0cm; whereas those with Gagne Indices 0-1 experience a survival benefit for AAAs larger than 5.5 cm. CONCLUSION The current data suggest that EVAR decreases 1-year mortality rates for patients of advanced age compared to non-operative management in the elderly. However, the survival benefit is largely limited to those with Gagne Indices 0-1 with AAAs ≥ 5.5 cm and Gagne Indices 2-5 with AAAs ≥ 7.0 cm. Those of advanced age may benefit from EVAR, but realizing this benefit requires careful patient selection.
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Affiliation(s)
- Mitri K Khoury
- Division of Vascular and Endovascular Surgery, Department of Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Micah A Thornton
- Department of Statistical Science, Southern Methodist University, Dallas, TX, USA
| | - Christopher A Heid
- Department of Cardiovascular and Thoracic Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Jacqueline Babb
- Division of Vascular and Endovascular Surgery, Department of Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Bala Ramanan
- Division of Vascular and Endovascular Surgery, Department of Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA
- Surgical Services, Dallas VA Medical Center, Dallas, TX, USA
| | - Shirling Tsai
- Division of Vascular and Endovascular Surgery, Department of Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA
- Surgical Services, Dallas VA Medical Center, Dallas, TX, USA
| | - Melissa L Kirkwood
- Division of Vascular and Endovascular Surgery, Department of Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Carlos H Timaran
- Division of Vascular and Endovascular Surgery, Department of Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - J Gregory Modrall
- Division of Vascular and Endovascular Surgery, Department of Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA
- Surgical Services, Dallas VA Medical Center, Dallas, TX, USA
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What factors counteract mid-term survival following endovascular repair of abdominal aortic aneurysms? POLISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2021; 18:8-14. [PMID: 34552638 PMCID: PMC8442091 DOI: 10.5114/kitp.2021.105179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 01/28/2021] [Indexed: 11/17/2022]
Abstract
Introduction Endovascular aortic aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) is increasingly used, and has become the standard treatment option for AAA. Aim To evaluate the outcomes and predictors of survival of endovascular treatment of AAA in the short- and medium-term. Material and methods A total of 222 patients having endovascular AAA repair between January 2013 and December 2019 by the same surgical team were included in the study. Patient demographics, perioperative and follow-up data including mortality, complications, and need for secondary intervention were collected. The primary endpoint was all-cause mortality. Kaplan-Meier analysis was conducted for survival and Cox regression models were assessed for predictors of survival. Results The median age was 70 years, with male predominance (202 patients, 91%). Thirty-day mortality was 1.8%. Median follow-up to the primary endpoint was 20 months (range: 1–80 months). Survival rates at 1, 3, and 5 years were 93.5%, 81.4%, and 62.2%, respectively. Freedom from secondary intervention rates were 95.5% at 1 year, 88.7% at 3 years, and 82.1% at 5 years. Cox proportional hazard models showed that preoperative creatinine levels ≥ 1.8 mg/dl (hazard ratio (HR) = 2.68, 95% CI: 1.21–6.42, p = 0.027), haemoglobin levels < 10 gr/dl (HR = 3.38, 95% CI: 1.16–9.90, p = 0.026), ejection fraction < 30% (HR = 5.67, 95% CI: 1.29–24.86, p = 0.021), and AAA diameter ≥ 6.0 cm (HR = 2.20, 95% CI: 1.01–4.81, p = 0.049) were independently associated with mid-term survival. Conclusions EVAR is a safe procedure with low postoperative morbidity and mortality. This study confirms that the mid-term survival and results are favourable. However, the analysed factors in this study that predict reduced survival (high preoperative creatinine, low haemoglobin, low ejection fraction and larger aneurysms) should be judged when planning endovascular repair of AAA.
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Nejim B, Chau M, Ramirez Castello C, Aziz F, Flohr TR. Preoperative Leukocytosis Among Female Patients Predicts Poor Postoperative Outcomes Following EVAR For Intact Infrarenal AAA. J Vasc Surg 2021; 74:1843-1852.e3. [PMID: 34174377 DOI: 10.1016/j.jvs.2021.05.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Accepted: 05/17/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Elevated white blood count (WBC) can be predictive of adverse outcomes following vascular interventions, but the association has not established using multi-institutional data. We evaluated the predictive value of preoperative WBC after endovascular abdominal aortic aneurysm repair (EVAR) for non-ruptured abdominal aortic aneurysms (AAA) in a nationally representative surgical database. METHODS Patients with non-ruptured AAA undergoing EVAR were identified in the vascular-targeted National Surgical Quality Improvement Program (NSQIP) database. Baseline characteristics were compared between patients with WBC < 10 K/μL and WBC ≥ 10 K/μL. Multivariable logistic regression analyses were performed to assess the odds of outcomes. The primary outcome was 30-day mortality. Multiple secondary outcomes including length of stay (LOS) > 1 week, 30-day readmission, lower extremity (LE) ischemia, ischemic colitis, myocardial infarction (MI) and others were assessed based on WBC and patient sex. RESULTS A total of 10955 patients were included with a mean WBC 7.7 ± 2.7 K/μL. Patients with WBC ≥ 10 K/μL were younger (71.8 ± 9.5 years versus 74.1 ± 8.7 years; P < .001) and were more likely to be diabetic, on steroids, smokers, functionally dependent and presenting emergently (all P ≤ .009). Aneurysm diameter was larger in WBC ≥ 10 K/μL patients (5.9 ± 1.5 cm versus 5.7 ± 1.5 cm; P < .001). Patients with WBC ≥ 10 K/μL had more mortality (2.4% vs 1.3%), LOS > 1 week (13.5% versus 6.7%), 30-day readmissions (9.8% versus 7.3%), LE ischemia (2.3% vs 1.4%), ischemic colitis (1.2% vs 0.5%), and MI (2.0% vs 1.1% ) (all P ≤ .008). Female patients with WBC ≥ 10 K/μL, compared to male patients with WBC ≥ 10 K/μL had more adverse events including mortality, LOS > 1 week, 30-day readmission, LE ischemia (all P ≤ .025). With each incremental increase in WBC by 1K/μL, the adjusted odds ratio of adverse outcomes for all patient was higher (mortality: 1.05 [95% CI, 1.00-1.10], readmission: 1.03 [95% CI, 1.00-1.06], LOS > 1 week: 1.08 [95% CI, 1.05-1.10] and ischemic colitis: 1.11 [95% CI, 1.05-1.16]; all P < .05). The effect was more pronounced in female patients and statistically significant. CONCLUSIONS WBC is a predictor of adverse outcomes in patients undergoing EVAR for non-ruptured AAA. After adjusting for associated risk factors, the effect of increasing WBC was more prominent for female patients. Preoperative WBC should be used as a prognostic factor to predict adverse outcomes among EVAR patients.
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Affiliation(s)
- Besma Nejim
- Pennsylvania State University College of Medicine and Penn State Heart and Vascular Institute, Hershey, Pa.
| | - Marvin Chau
- Pennsylvania State University College of Medicine and Penn State Heart and Vascular Institute, Hershey, Pa
| | - Camilla Ramirez Castello
- Pennsylvania State University College of Medicine and Penn State Heart and Vascular Institute, Hershey, Pa
| | - Faisal Aziz
- Pennsylvania State University College of Medicine and Penn State Heart and Vascular Institute, Hershey, Pa
| | - Tanya R Flohr
- Pennsylvania State University College of Medicine and Penn State Heart and Vascular Institute, Hershey, Pa
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Tumer NB, Askin G, Akkaya BB, Civelek I, Unal EU, Iscan HZ. Outcomes after EVAR in females are similar to males. BMC Cardiovasc Disord 2021; 21:301. [PMID: 34130661 PMCID: PMC8207773 DOI: 10.1186/s12872-021-02114-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Accepted: 06/07/2021] [Indexed: 01/15/2023] Open
Abstract
INTRODUCTION Women are less likely to develop infrarenal abdominal aortic aneurysm; however, when they do, it is almost always associated with challenging anatomy, more rapid aneurysmal growth rate and earlier rupture. Women generally have poorer outcomes following open aneurysm repair; and in this respect, the present study aims to evaluate if it is so after endovascular repair. METHODS A retrospective analysis of our database was performed for patients underwent endovascular aneurysm repair (EVAR) between January 2013-March 2020. 249 elective EVAR patients were evaluated. Patients were categorized according to gender and 26 patients (10.4%) were female. Demographics and pre-peri-postoperative findings were compared. Propensity score matching (ratio 1:1) was performed to reduce selection bias. RESULTS In the overall unmatched cohort, female population had more diabetes mellitus (p = 0.016) and hypertension (p = 0.005). However, coronary artery disease (p = 0.005) and coronary artery bypass grafting (p = 0.006) were more in male gender. Non-IFU implantation was higher in female group (38.5% vs. 11.5%, p = 0.025). After propensity matching, even though it was not statistically significant, early mortality for female gender was higher when compared to male gender (7.7% and 0%, respectively, p = 0.490). In the follow-up period, no difference in all-cause mortality, secondary interventions or complications have been observed between the genders. CONCLUSION Challenging anatomy and subsequently treated patients outside IFU may be the reasons for higher morbidity and mortality in women. However, despite these factors female and male patients revealed equivalent early and late results.
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Affiliation(s)
- Naim Boran Tumer
- Department of Cardiovascular Surgery, Ankara City Hospital, Ankara, Turkey.
| | - Goktan Askin
- Department of Cardiovascular Surgery, Ankara City Hospital, Ankara, Turkey
| | | | - Isa Civelek
- Department of Cardiovascular Surgery, Ankara City Hospital, Ankara, Turkey
| | - Ertekin Utku Unal
- Department of Cardiovascular Surgery, Hitit University Erol Olcok Training and Research Hospital, Çorum, Turkey
| | - Hakki Zafer Iscan
- Department of Cardiovascular Surgery, Ankara City Hospital, Ankara, Turkey
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13
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Association of Medicaid Expansion with In-Hospital Outcomes After Abdominal Aortic Aneurysm Repair. J Surg Res 2021; 266:201-212. [PMID: 34022654 DOI: 10.1016/j.jss.2021.02.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 02/08/2021] [Accepted: 02/27/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Multiple studies have shown improved outcomes and higher utilization of care with the increase of insurance coverage. This study aims to assess whether Medicaid expansion (ME) has changed the utilization and outcomes of abdominal aortic aneurysm (AAA) repair in the United States. DESIGN Retrospective observational study. MATERIALS Data of patients undergoing AAA repair in the Vascular Quality Initiative (2010-2017). METHODS Interrupted time-series (ITS) analysis was utilized to evaluate changes in annual trends of postoperative outcomes after elective AAA repair before and after 2014. We also assessed if these trend changes were significant by comparing the changes in states which adopted ME in 2014 versus nonexpansion states (NME), and conducting a difference-in-difference analysis. Primary outcomes included in-hospital mortality and adverse events (bowel and leg ischemia, cardiac, renal, respiratory, stroke and return to the OR). RESULTS A total of 19,143 procedures were included (Endovascular: 85.8% and open: 14.2%), of which 40.9% were performed in ME States. Compared to preexpansion trends (P1), there was a 2% annual increase in elective AAA repair in ME states (P1: -1.8% versus P2: +0.2%, P< 0.01) with no significant change in NME (P1: +0.3% versus P2: +0.2%, P = 0.97). Among elective cases, annual trends in the use of EVAR increased by 2% in ME states (95% confidence interval (CI) = -0.1, 4.1, P = 0.06), compared to a 3% decrease in NME States [95%CI = -5.8, -0.6, P = 0.01) (PMEversusNME < 0.01]. There was no association between ME and in-hospital mortality. Nonetheless, it was associated with a decrease in the annual trends of in-hospital complications (ME: -1.4% (-2.1,-0.8) versus NME: +0.2% (-0.2, +0.8), P < 0.01). CONCLUSIONS While no association between ME and increased survival was noted in states which adopted ME, there was a significant increase of elective AAA cases and EVAR utilization and a decrease in in-hospital complications in ME States.
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Charlton-Ouw KM, Ikeno Y, Bokamper M, Zakhary E, Smeds MR. Aortic endograft sizing and endoleak, reintervention, and mortality following endovascular aneurysm repair. J Vasc Surg 2021; 74:1519-1526.e2. [PMID: 33940075 DOI: 10.1016/j.jvs.2021.04.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 04/10/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Endograft sizing for endovascular abdominal aortic aneurysm repair (EVAR) is not consistent despite published instructions for use (IFU). We sought to identify factors associated with over/undersizing, determine sex influence on sizing, and examine sizing effects on endoleak, reintervention, and mortality by analyzing data obtained from the W.L. Gore & Associates Global Registry for Endovascular Aortic Treatment (GREAT). METHODS All patients enrolled in GREAT undergoing EVAR were included for analysis. Proximal/distal aortic landing zones were compared with device implanted to assess sizing as related to IFU. χ2/Fisher exact tests were used to evaluate associations between IFU sizing and demographics. Logistic regression modeling was used to identify predictors of outside IFU sizing. Cox proportional hazards regression analyzed the relationship between sizing and endoleak, device-related reinterventions, and all-cause/aortic mortality. RESULTS There were 3607 EVAR subjects enrolled in GREAT as of March 2020. Of them, 1896 (53%) were within IFU for sizing, 791 (22%) were oversized, 540 (15%) were undersized, and 380 (10%) had both over- and undersized components. Factors predictive of use outside of IFU included female sex (P = .001), non-white race (P = .0003), decreased proximal neck length (P < .061), or larger iliac diameters (P < .0001). Women were more likely than men to have proximal neck undersizing and iliac limb oversizing, and men were more likely to have iliac limb undersizing. On multivariate analysis, undersizing of the proximal graft was associated with endoleak (hazard ratio [HR], 1.8) and aortic (HR, 60.5) and all-cause (HR, 18.0) mortality. Undersizing of iliac limbs was associated with endoleak (HR, 1.5) and device-related reintervention (HR, 1.4). Iliac limb outside IFU sizing was associated with aortic (HR, 2.6) and all-cause (HR, 1.3) mortality. Proximal and distal oversizing was not associated with adverse outcomes. Female sex was associated with mortality on univariate but not multivariate analysis. CONCLUSIONS Women undergoing EVAR with GORE EXCLUDER abdominal aortic aneurysm Endoprosthesis (W.L. Gore & Associates Inc, Flagstaff, Ariz) are more likely to have proximal stent-graft undersizing and iliac limb oversizing, whereas men are more likely to have undersized iliac limbs. Proximal aortic graft undersizing is associated with endoleak and all-cause/aortic mortality, whereas undersizing of iliac limbs is associated with endoleak and device-related reintervention. Oversizing was not associated with adverse outcomes.
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Affiliation(s)
- Kristofer M Charlton-Ouw
- HCA Houston Healthcare, Gulf Coast Division, Department of Clinical Sciences, University of Houston College of Medicine, Houston, Tex; Division of Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center at Houston (UTHealth), Houston, Tex
| | - Yuki Ikeno
- Division of Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center at Houston (UTHealth), Houston, Tex
| | - Matthew Bokamper
- Division of Vascular and Endovascular Surgery, Department of Surgery, Saint Louis University School of Medicine, St. Louis, Mo
| | - Emad Zakhary
- Division of Vascular and Endovascular Surgery, Department of Surgery, Saint Louis University, St. Louis, Mo
| | - Matthew R Smeds
- Division of Vascular and Endovascular Surgery, Department of Surgery, Saint Louis University, St. Louis, Mo.
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Octeau D, Faries C, Barnes H, Nakazawa KR, Rao AJ, Ting W, Marin ML, Vouyouka AG, Faries PL, Tadros RO. Neutrophil-to-Lymphocyte Ratio Associated With Adverse Events After Endovascular Aneurysm Repair (EVAR). Ann Vasc Surg 2021; 75:45-54. [PMID: 33865942 DOI: 10.1016/j.avsg.2021.02.040] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 02/08/2021] [Accepted: 02/09/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND The blood neutrophil-to-lymphocyte ratio (NLR) is a surrogate biomarker of systemic inflammation with important prognostic significance in multiple disease processes, including cardiovascular diseases. It is inexpensive, widely available, and may be related to the outcomes of patients after surgery. We aimed to investigate the possible association of NLR with the outcomes of patients following endovascular aneurysm repair (EVAR). METHODS This single-center, retrospective study of a prospectively maintained database evaluated 777 patients with a diagnosed abdominal aortic aneurysm (AAA) who underwent EVAR and were longitudinally followed between 2001 and 2017. NLR was defined as the ratio of absolute neutrophil count to absolute lymphocyte count. The mortality and reinterventions were used to evaluate outcomes using the appropriate univariate models, and the effect of clinical variables on NLR was further investigated using multivariate modelling. RESULTS The median NLR for all patients was 3 IQR [2.2 - 4.6]. A cut-off point of 3.6 was uncovered in a training set of 388 patients using the maximally ranked statistic method. Patients with NLR < 3.6 had significantly improved mortality rates (P< 0.0001) in the training set, and results were internally validated in a testing set of 389 patients (P = 0.042). Multivariate analysis revealed that high NLR (HR 1.4 95% CI [1.0 - 2.0]; P< 0.05) remained an independent predictor of mortality in a multivariate analysis controlling for characteristics such as comorbidities, age, and maximal aortic diameter. 5-year mortality and 30-day, 1-year and 5-year reinterventions were all higher in the high NLR group. CONCLUSION High NLR was significantly associated with higher rates of death at 5 years as well as higher rates of reinterventions at 30 days, 1 year and 5 years. We also suggest that an internally validated cut-off point of NLR >3.6 may be clinically important to help segregate patients into high and low NLR categories. It remains unclear whether NLR is directly linked to adverse events post-EVAR or whether it is a surrogate for an inflammatory state that predisposes patients to higher risk of death or reinterventions.
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Affiliation(s)
- David Octeau
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Christopher Faries
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Hanna Barnes
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Kenneth R Nakazawa
- Division of Vascular Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ajit J Rao
- Division of Vascular Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Windsor Ting
- Division of Vascular Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Michael L Marin
- Division of Vascular Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ageliki G Vouyouka
- Division of Vascular Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Peter L Faries
- Division of Vascular Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Rami O Tadros
- Division of Vascular Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY.
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Erben Y, Li Y, Hamid OS, Franco-Mesa C, Da Rocha-Franco JA, Money S, Stone W, Farres H, Meltzer AJ, Gloviczki P, De Martino RR, Bower TC, Kalra M, Oderich GS, Hakaim AG. Women have similar mortality but higher morbidity than men after elective endovascular abdominal aortic aneurysm repair. J Vasc Surg 2021; 74:451-458.e1. [PMID: 33548430 DOI: 10.1016/j.jvs.2020.12.095] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 12/30/2020] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Sex disparities regarding outcomes for women after open and endovascular abdominal aortic aneurysm repair have been well-documented. The purpose of this study was to review whether these disparities were also present at our institution for elective endovascular aneurysm repair (EVAR) and whether specific factors predispose female patients to negative outcomes. METHODS All elective EVARs were identified from our three sites (Florida, Minnesota, and Arizona) from 2000 to 2018. The primary outcome was in-hospital mortality and three-year mortality. Secondary outcomes included complications requiring return to the operating room, length of hospitalization (LOH), intensive care unit (ICU) days, and location of discharge after hospitalization. Multivariable logistic regression models were used to assess for the risk of complications. RESULTS There were 1986 EVARs; 1754 (88.3%) were performed in male and 232 (11.7%) in female patients. Female patients were older (79 years [interquartile range (IQR), 72-83 years] vs 76 years [IQR, 70-81 years]; P < .001), had a lower body mass index (median, 26.1 kg/m2 [IQR, 22.1-31.0 kg/m2] vs 28.3 kg/m2 [IQR, 25.3-31.6 kg/m2]; P < .001 and hematocrit (median, 37.6% [IQR, 33.4%-40.6%] vs 39.4% [IQR, 35.6%-42.6%]; P < .001) and had higher glomerular filtration rate (median, 84.4 mL/min per 1.73m2 [IQR, 62.3-103 mL/min/1.73 m2] vs 51.1 mL/min/1.73 m2 [IQR, 41.8-60.8 mL/min/1.73 m2]; P < .001. Female patients were also more likely to be active smokers (15.3% vs 13.1%; P < .001) and have chronic obstructive pulmonary disease (24.7% vs 15.3%; P = .001). They were less likely to have coronary artery disease (31.6% vs 45.6%; P < .001). Aneurysms in women were slightly smaller in size (median, 54 mm [IQR, 50.0-58.0 mm] vs 55 mm [IQR, 51.0-60.0 mm]; P = .004). In-hospital mortality and mortality at the 3-year follow-up was not significant between female and male patients (0.86% vs 0.17%; P = .11 and 38.4% vs 36.2%; P = .57). However, female patients returned to the operating room with a greater frequency than male patients (3.9% vs 1.4%; P = .011). LOH (mean, 3.4 ± 3.8 days vs 2.5 ± 2.4 days; P < .001) and ICU days (mean, 0.3 ± 2.0 days vs 0.1 ± 0.5 days; P < .001) were longer for female patients. After hospitalization, female patients were discharged to rehabilitation facilities in greater proportion (12.7% vs 3.1%; P < .001) than their male counterparts. On multivariable analysis, female sex was associated with a return to the operating room (odds ratio, 6.4; 95% confidence interval [CI], 1.4-3.5; P = .02), longer LOH (Coef 4.0; 95% CI, 1.0-2.5; P = .00007), more ICU days (Coef 2.8; 95% CI, 1.1-3.0; P = .005), and a greater likelihood of posthospitalization rehabilitation facility placement (odds ratio, 5.8; 95% CI, 1.5-2.4; P = .0001). CONCLUSIONS Our three-site, single-institution data support sex disparities to the detriment of female patients regarding return to the operating room after EVAR, LOH, ICU days, and discharge to rehabilitation facility. However, we found no differences for in-hospital or 3-year mortality.
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Affiliation(s)
- Young Erben
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Jacksonville, Fla.
| | - Yupeng Li
- Department of Political Science and Economics, Rowan University, Glassboro, NJ
| | - Osman S Hamid
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Jacksonville, Fla
| | - Camila Franco-Mesa
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Jacksonville, Fla
| | | | - Samuel Money
- Department of Surgery, Ochsner Clinic, New Orleans, La
| | - William Stone
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Scottsdale, Ariz
| | - Houssam Farres
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Jacksonville, Fla
| | - Andrew J Meltzer
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Scottsdale, Ariz
| | - Peter Gloviczki
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn
| | | | - Thomas C Bower
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Manju Kalra
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Gustavo S Oderich
- Department of Cardiovascular Surgery, University of Texas in Houston, Houston, Tex
| | - Albert G Hakaim
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Jacksonville, Fla
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Behrendt CA, Kreutzburg T, Kuchenbecker J, Panuccio G, Dankhoff M, Spanos K, Kouvelos G, Debus S, Peters F, Kölbel T. Female Sex and Outcomes after Endovascular Aneurysm Repair for Abdominal Aortic Aneurysm: A Propensity Score Matched Cohort Analysis. J Clin Med 2021; 10:jcm10010162. [PMID: 33466535 PMCID: PMC7796519 DOI: 10.3390/jcm10010162] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 01/01/2021] [Accepted: 01/02/2021] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE Previous studies have showed a potential disadvantage of female patients who underwent abdominal aortic aneurysm (AAA) repair. The current study aims to determine sex-specific perioperative and long-term outcomes using propensity score matched unselected nationwide health insurance claims data. METHODS Insurance claims from a large German fund were used, covering around 8% of the insured German population. Patients who underwent endovascular aortic repair (EVAR) for intact AAA from 1 January 2011 to 30 April 2017 were included in the cohort. A 1:2 female to male propensity score matching was applied to adjust for confounding variables. Perioperative and long-term outcomes after 5 years were determined using matching and regression methods. RESULTS Among a total of 3736 patients (19.3% females, mean 75 years) undergoing EVAR for intact AAA, we identified 1863 matched patients. Before matching, females were more likely to be previously diagnosed with hypothyroidism, electrolyte disorders, rheumatoid disorders, and depression, while males were more often diabetics. In the matched sample, 23.4% of the females and 25.8% of the males died during a median follow-up of 776 and 792 days, respectively. Perioperatively, females were more likely to exhibit acute limb ischemia (5.3% vs. 3.2%, p = 0.031) and major bleeding (22.0% vs. 15.9%, p = 0.001) before they were discharged to rehabilitation (5.5% vs. 1.5%, p < 0.001) when compared to males. No statistically significant difference in perioperative (odds ratio 1.12, 95% CI 0.54-2.16) or long-term mortality (hazard ratio 0.91, 95% CI 0.76-1.08) was observed between sexes. This was also true regarding aortic reintervention rates after 1 year (2.0% vs. 2.9%) and 5 years (10.9% vs. 8.1%). CONCLUSION The current retrospective matched analysis of insurance claims revealed high early access-related morbidity in females when compared to their male counterparts. Short-term or long-term survival and reintervention outcomes were similar between sexes.
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Affiliation(s)
- Christian-Alexander Behrendt
- Research Group GermanVasc, Department of Vascular Medicine, University Heart and Vascular Center UKE Hamburg, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany; (T.K.); (J.K.); (S.D.); (F.P.)
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart and Vascular Center UKE Hamburg, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany; (G.P.); (K.S.); (T.K.)
- Correspondence: ; Tel.: +49-40-7410-18087; Fax: +49-40-7410-54840
| | - Thea Kreutzburg
- Research Group GermanVasc, Department of Vascular Medicine, University Heart and Vascular Center UKE Hamburg, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany; (T.K.); (J.K.); (S.D.); (F.P.)
| | - Jenny Kuchenbecker
- Research Group GermanVasc, Department of Vascular Medicine, University Heart and Vascular Center UKE Hamburg, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany; (T.K.); (J.K.); (S.D.); (F.P.)
| | - Giuseppe Panuccio
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart and Vascular Center UKE Hamburg, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany; (G.P.); (K.S.); (T.K.)
| | | | - Konstantinos Spanos
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart and Vascular Center UKE Hamburg, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany; (G.P.); (K.S.); (T.K.)
- Department of Vascular Surgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, 41334 Larissa, Greece;
| | - George Kouvelos
- Department of Vascular Surgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, 41334 Larissa, Greece;
| | - Sebastian Debus
- Research Group GermanVasc, Department of Vascular Medicine, University Heart and Vascular Center UKE Hamburg, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany; (T.K.); (J.K.); (S.D.); (F.P.)
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart and Vascular Center UKE Hamburg, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany; (G.P.); (K.S.); (T.K.)
| | - Frederik Peters
- Research Group GermanVasc, Department of Vascular Medicine, University Heart and Vascular Center UKE Hamburg, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany; (T.K.); (J.K.); (S.D.); (F.P.)
| | - Tilo Kölbel
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart and Vascular Center UKE Hamburg, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany; (G.P.); (K.S.); (T.K.)
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Pasqui E, de Donato G, Giannace G, Panzano C, Setacci C, Palasciano G. Management of abdominal aortic aneurysm in nonagenarians: A single-centre experience. Vascular 2020; 29:27-34. [PMID: 32611281 DOI: 10.1177/1708538120936831] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE In the last decades, life expectancy has increased worldwide considerably. Traditionally, very elderly patients have been considered too frail to undergo major vascular interventions. Considering that abdominal aortic aneurysm is an age-related disease, there is an increasing need of a correct management of the disease even in nonagenarians, but data are still scarce. The purpose of this single-centre study is to report early and mid-term outcomes of all-comer abdominal aortic aneurysm patients in their 10th decades of age. METHODS A retrospective review of our prospectively maintained database identified a total of 33 patients aged ≥ 90 presenting with abdominal aortic aneurysm between 2014 and 2019. Elective and emergency repairs were both considered. Early technical success and mortality rate at 30 days were considered as primary outcomes. Mid-term clinical success was reported, and overall survival, freedom from aneurysm-related death, re-interventions and endoleaks were estimated with the Kaplan-Meier method, stratified for elective of emergency repair and type of treatment. RESULTS The mean age was 91.7 (range 90-96), and 63.6% were male. Mean abdominal aortic aneurysm diameter was 67.4 ± 16.8 mm. Sixteen patients were admitted for rupture abdominal aortic aneurysm: three untreated, five underwent open and seven underwent endovascular aneurysm repair (EVAR), with an early mortality rate of 100, 100 and 42.8%, respectively. Eighteen (60%) patients were asymptomatic, and all underwent elective EVAR, with an early mortality rate of 0%. At one-month follow-up, clinical success was 84% in EVAR group. At a median follow-up of 22.4 ± 14.5 months, no abdominal aortic aneurysm-related death was registered. Freedom from all cause of mortality was 77.3, 59.4 and 40.7% at one, two and three years. Freedom from endoleaks was 95.4% at one month and 61.7% at one and three years. Freedom from reintervention was 85.8% at three years. CONCLUSION Elective EVAR in nonagenarians is associated with acceptable early and mid-term outcomes. Age by itself should not be considered an exclusion criterion for treatment.
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Affiliation(s)
- Edoardo Pasqui
- Department of Medicine, Surgery and Neuroscience, Vascular Surgery Unit, 9313University of Siena, Siena, Italy
| | - Gianmarco de Donato
- Department of Medicine, Surgery and Neuroscience, Vascular Surgery Unit, 9313University of Siena, Siena, Italy
| | - Giovanni Giannace
- Department of Medicine, Surgery and Neuroscience, Vascular Surgery Unit, 9313University of Siena, Siena, Italy
| | - Claudia Panzano
- Department of Medicine, Surgery and Neuroscience, Vascular Surgery Unit, 9313University of Siena, Siena, Italy
| | - Carlo Setacci
- Department of Medicine, Surgery and Neuroscience, Vascular Surgery Unit, 9313University of Siena, Siena, Italy
| | - Giancarlo Palasciano
- Department of Medicine, Surgery and Neuroscience, Vascular Surgery Unit, 9313University of Siena, Siena, Italy
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Sex Disparity in Outcomes of Ruptured Abdominal Aortic Aneurysm Repair Driven by In-hospital Treatment Delays. Ann Surg 2020; 270:630-638. [PMID: 31356266 DOI: 10.1097/sla.0000000000003482] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE We sought to assess whether sex-related differences in timely repair of ruptured abdominal aortic aneurysm (rAAA) were associated with excess risk of early mortality in women. SUMMARY BACKGROUND DATA rAAA is a surgical emergency and timeliness of intervention affects outcomes. A door-to-intervention time of <90 minutes is recommended. METHODS All rAAA repairs in the Vascular Quality Initiative from 2003 to 2017 were reviewed. Patients were stratified by sex and time-delay cohorts. Univariate and multivariate analyses were performed. RESULTS There were 3719 rAAA repairs, of which 797 (21%) were performed in women. Sex did not affect repair type: open versus endovascular (21% females, each). Despite similar presentation delays [median 6 hours (inter quartile range, IQR: 3-16)], admission-to-intervention time was longer for women than men [median 1.5 hours (IQR 1-4] vs 1.2 hours (IQR 1-3), P=0.047]. Overall, 45% of patients had a >90-minute delay from admission to repair, with more women than men experiencing this delay (49% vs 44%, P=0.01). Neither were more likely to undergo transfer for treatment. After risk adjustment, female sex was associated with a 48% increase in 30-day mortality. Sex differences in mortality were no longer observed in patients with intervention delays of ≤90 minutes. In patients with >90-minute delays, a 77% increase in 30-day mortality of women over men was noted. CONCLUSIONS Nearly half of rAAA patients have a door-to-intervention time longer than recommended societal guidelines. Sex differences in mortality after rAAA repair seem to be driven by in-hospital treatment delays.
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Ramkumar N, Suckow BD, Arya S, Sedrakyan A, Mackenzie TA, Goodney PP, Brown JR. Association of Sex With Repair Type and Long-term Mortality in Adults With Abdominal Aortic Aneurysm. JAMA Netw Open 2020; 3:e1921240. [PMID: 32058556 DOI: 10.1001/jamanetworkopen.2019.21240] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
IMPORTANCE Sex-based differences exist in the prevalence and clinical presentation of abdominal aortic aneurysm (AAA). However, it is unclear if sex is associated with AAA repair type and long-term mortality. OBJECTIVE To investigate whether a sex-related difference exists in mortality risk after AAA repair owing to differences in repair type. DESIGN, SETTING, AND PARTICIPANTS This cohort study uses data from the Vascular Quality Initiative, a national clinical registry, and Medicare claims to investigate endovascular and surgical repair procedures performed between January 1, 2003, and September 30, 2015, in patients aged 65 years or older with AAA. The data were analyzed from October 1, 2018, to November 19, 2019. EXPOSURE Sex of the patient. MAIN OUTCOMES AND MEASURES Endovascular (EVR) or open surgical AAA repair type and subsequent long-term, all-cause mortality. RESULTS In this cohort study of 16 386 patients, 12 757 (77.9%) were men and 3629 (22.1%) were women. Women were more likely than men to be older (mean [SD] age, 77 [6.5] years vs 75 [6.6] years; P < .001), active smokers (33% vs 28%; P < .001), and to have smaller aneurysms (mean [SD] diameter, 57 [11.7] mm vs 59 [17.7] mm; P < .001). Surgical AAA repair was performed in 27% (983 of 3629) of women compared with 18% (2328 of 12 757) of men (P < .001). After inverse probability weighting for risk adjustment, women were more likely to receive open surgical repair than EVR repair (risk ratio, 1.65; 95% CI, 1.51-1.80). The 10-year unadjusted survival rate after EVR repair was 14% lower in women than in men (23% vs 37%; log-rank P < .001), but the rates were comparable after open surgical repair (36% in men vs 32% in women; log-rank P = .22). Risk-adjusted analysis showed that women were associated with higher mortality rates after EVR repair (hazard ratio, 1.13; 95% CI, 1.03-1.24), whereas both men and women had a similar risk of death after open surgical repair (hazard ratio, 0.94; 95% CI, 0.84-1.06). After further stratification by symptom severity, higher risk of mortality among women was limited to elective EVR and open surgical repair for ruptured AAA. CONCLUSIONS AND RELEVANCE In this study, women were 65% more likely than men to undergo open surgical repair. After EVR repair, women were 13% more likely to die than men, although no sex-based difference in mortality was found after open surgical repair. The differential treatment benefit of EVR repair in women is concerning given the shift toward an EVR-first approach to AAA repair.
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Affiliation(s)
- Niveditta Ramkumar
- The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, New Hampshire
| | - Bjoern D Suckow
- Section of Vascular Surgery, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Shipra Arya
- Department of Surgery, Stanford University Medical Center, Stanford, California
| | - Art Sedrakyan
- Department of Healthcare Policy and Research, Weill Cornell Medical College, Cornell University, New York, New York
| | - Todd A Mackenzie
- The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, New Hampshire
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Philip P Goodney
- The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, New Hampshire
- Section of Vascular Surgery, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Jeremiah R Brown
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
- Department of Epidemiology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
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Varkevisser RR, O'Donnell TF, Swerdlow NJ, Liang P, Li C, Ultee KH, Patel VI, Scali ST, Verhagen HJ, Schermerhorn ML. Factors associated with in-hospital complications and long-term implications of these complications in elderly patients undergoing endovascular aneurysm repair. J Vasc Surg 2020; 71:470-480.e1. [DOI: 10.1016/j.jvs.2019.03.059] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 03/26/2019] [Indexed: 12/21/2022]
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Systematic review and meta-analysis of sex differences in outcomes after endovascular aneurysm repair for infrarenal abdominal aortic aneurysm. J Vasc Surg 2020; 71:283-296.e4. [DOI: 10.1016/j.jvs.2019.06.105] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 06/04/2019] [Indexed: 12/21/2022]
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Locham S, Shaaban A, Wang L, Bandyk D, Schermerhorn M, Malas MB. Impact of Gender on Outcomes Following Abdominal Aortic Aneurysm Repair. Vasc Endovascular Surg 2019; 53:636-643. [DOI: 10.1177/1538574419868040] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Objective: The purpose of this study is to use a large, nationally representative vascular database to assess differences in patient characteristics, aortic neck anatomy, and outcomes between men and women following open (open aneurysm repair [OAR]) and endovascular (endovascular aneurysm repair [EVAR]) abdominal aortic aneurysm (AAA) repair. Methods: Patients undergoing AAA repair from 2003 to 2018 in Vascular Quality Initiative were identified and stratified by procedure (EVAR vs OAR). Thirty-day mortality and major in-hospital complications were assessed between genders within each operative cohort. An EVAR subset analysis was performed to assess differences in aortic neck anatomy; hostile neck anatomy was defined as length <15 mm (L < 15), angle >60° (A > 60), and/or diameter >28 mm (D > 28). Standard univariate and multivariable analyses were performed. Results: A total of 50 213 patients were identified: 9263 (19%) OAR and 40 950 (82%) EVAR. In both cohorts, majority of patients were men (OAR 73% and EVAR 81%). Women were more likely to have a hostile neck (31.7% vs 24.1%, P < .001), L < 15 (19.8% vs 11.9%, P < .001), and A > 60 (11.5% vs 5.4%, P < .001). Men had larger aneurysm (mean, 57 vs 55 mm, P < .001) and were more likely to have D > 28 (14.0% vs 10.6%, P < .001). Women undergoing EVAR were more likely to undergo aortic extensions (21.9% vs 16.0%) and receive higher contrast volume. After adjusting for potential confounders, female gender was associated with 86% and 50% increased risk of 30-day mortality in OAR and EVAR, respectively. Women were more likely than men to experience renal, cardiac, and pulmonary complications only in the EVAR cohort. Women had a 2-fold increased odds of developing type 1 endoleak. Conclusion: Our study demonstrates unfavorable neck anatomy occurs more frequently in women compared to men. Women were also at an increased risk of developing major complications, particularly following EVAR. Careful patient selection is indicated in all patients to reduce complications, with special attention in women with hostile neck.
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Affiliation(s)
| | | | - Linda Wang
- Massachusetts General Hospital, Boston, MA, USA
| | - Dennis Bandyk
- University of California San Diego, La Jolla, CA, USA
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Collapsed bifurcated modular infrarenal endograft. J Vasc Surg 2019; 70:600-605. [DOI: 10.1016/j.jvs.2018.12.049] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 12/02/2018] [Indexed: 11/17/2022]
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Kim N, Choi SJ, Yoo BH, Lee S, Kim KM, Yon JH, Lee WY, Kim MC. Risk factors of 30-day mortality following endovascular thoracic and abdominal aortic repair with general anesthesia. Anesth Pain Med (Seoul) 2019. [DOI: 10.17085/apm.2019.14.3.305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Nari Kim
- Department of Anesthesiology and Pain Medicine, Inje University Sanggye Paik Hospital, Seoul, Korea
| | - Si Jin Choi
- Department of Anesthesiology and Pain Medicine, Inje University Sanggye Paik Hospital, Seoul, Korea
| | - Byung Hoon Yoo
- Department of Anesthesiology and Pain Medicine, Inje University Sanggye Paik Hospital, Seoul, Korea
| | - Sangseok Lee
- Department of Anesthesiology and Pain Medicine, Inje University Sanggye Paik Hospital, Seoul, Korea
| | - Kye-Min Kim
- Department of Anesthesiology and Pain Medicine, Inje University Sanggye Paik Hospital, Seoul, Korea
| | - Jun Heum Yon
- Department of Anesthesiology and Pain Medicine, Inje University Sanggye Paik Hospital, Seoul, Korea
| | - Woo Yong Lee
- Department of Anesthesiology and Pain Medicine, Inje University Sanggye Paik Hospital, Seoul, Korea
| | - Mun-Cheol Kim
- Department of Anesthesiology and Pain Medicine, Inje University Sanggye Paik Hospital, Seoul, Korea
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Nishibe T, Iwahashi T, Kamiya K, Takahashi S, Kawago K, Maruno K, Fujiyoshi T, Iwahori A, Suzuki S, Koizumi N, Koizumi J, Ogino H. Four-year experience with the Endurant stent-graft for abdominal aortic and common iliac artery aneurysms in 50 consecutive Japanese patients. INT ANGIOL 2019; 38:108-114. [DOI: 10.23736/s0392-9590.19.04023-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Shutze WP, Shutze R, Dhot P, Forge M, Salazar A, Ogola GO. Sex as an independent risk factor for long-term survival after endovascular aneurysm repair. J Vasc Surg 2019; 69:1080-1089.e1. [DOI: 10.1016/j.jvs.2018.07.057] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Accepted: 07/15/2018] [Indexed: 12/30/2022]
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Rate of Secondary Intervention After Open Versus Endovascular Abdominal Aortic Aneurysm Repair. J Surg Res 2018; 232:99-106. [DOI: 10.1016/j.jss.2018.05.073] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 05/15/2018] [Accepted: 05/31/2018] [Indexed: 11/18/2022]
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Jalalzadeh H, van Leeuwen CF, Indrakusuma R, Balm R, Koelemay MJW. Systematic review and meta-analysis of the risk of bowel ischemia after ruptured abdominal aortic aneurysm repair. J Vasc Surg 2018; 68:900-915. [PMID: 30146037 DOI: 10.1016/j.jvs.2018.05.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 05/14/2018] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- Hamid Jalalzadeh
- Department of Surgery and Amsterdam Cardiovascular Sciences, Academic Medical Center, Amsterdam, The Netherlands.
| | - Carlijn F van Leeuwen
- Department of Surgery and Amsterdam Cardiovascular Sciences, Academic Medical Center, Amsterdam, The Netherlands
| | - Reza Indrakusuma
- Department of Surgery and Amsterdam Cardiovascular Sciences, Academic Medical Center, Amsterdam, The Netherlands
| | - Ron Balm
- Department of Surgery and Amsterdam Cardiovascular Sciences, Academic Medical Center, Amsterdam, The Netherlands
| | - Mark J W Koelemay
- Department of Surgery and Amsterdam Cardiovascular Sciences, Academic Medical Center, Amsterdam, The Netherlands
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Affiliation(s)
- Ellen K Brinza
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
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31
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Locham S, Faateh M, Dakour-Aridi H, Nejim B, Malas M. Octogenarians Undergoing Open Repair Have Higher Mortality Compared with Fenestrated Endovascular Repair of Intact Abdominal Aortic Aneurysms Involving the Visceral Vessels. Ann Vasc Surg 2018; 51:192-199. [DOI: 10.1016/j.avsg.2018.02.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 02/08/2018] [Accepted: 02/11/2018] [Indexed: 01/24/2023]
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Some asymptomatic abdominal aortic aneurysms smaller than 5.5 cm can be considered for elective repair. J Vasc Surg 2018; 67:1645-1648. [DOI: 10.1016/j.jvs.2018.01.042] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Accepted: 01/17/2018] [Indexed: 11/23/2022]
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Truong C, Kugler NW, Rossi PJ, Patel PJ, Hieb RA, Brown KR, Lewis BD, Seabrook G, Lee CJ. Sex-dependent outcomes following elective endovascular aortic repair. J Surg Res 2018; 229:177-185. [PMID: 29936987 DOI: 10.1016/j.jss.2018.03.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Revised: 03/01/2018] [Accepted: 03/13/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Evidence has shown that women derive less benefit from endovascular aortic repair (EVAR) in large part due to more challenging aortoiliac anatomy. This study sought to examine whether sex-dependent outcomes exist following elective EVAR cases. METHODS An institutional retrospective review was performed on patients who underwent elective EVAR procedures between 2008 and 2014. Outcome data collected included procedural and hospital morbidity, mortality, and overall EVAR durability based on the incidence of unplanned graft-related secondary interventions (SIs) (e.g., open conversion, proximal or distal extensions, and coil embolizations). RESULTS One hundred eighty-one patients (150 men, 31 women) met the study inclusion criteria. Median follow-up was 40.3 mo. Women had more challenging anatomy compared to men including smaller overall iliac diameters (6.8 mm versus 8.0 mm, P < 0.001) and more severe iliac angulation (77% moderate to severe versus 44%, P < 0.001). Women had increased risk of postoperative complications compared to men (41.9% versus 11.3%, P = 0.003). There was no perioperative mortality in our series of elective EVAR cases. Median 5-y survival following EVAR was 64.4% for men and 76.3% for women (P = 0.599). Late SI rates following EVAR was 10.5% with 16 (10.7%) men and 3 (9.7%) women needing interventions (P = 0.870). Overall durability of EVAR extrapolated as time to SIs was 91% at 2 y and 85% at 5 y. Factors predisposing SIs were iliac tortuosity (P = 0.046), aortic neck angle (P = 0.022), and endoleak at the follow-up (P = 0.030). CONCLUSIONS In this study, immediate outcomes following EVAR were different between men and women, with women having increased rates of postoperative complications. Mortality and overall long-term durability of EVAR, however, were the same between sexes despite anatomical differences. EVAR durability was significantly dependent on the severity of iliac tortuosity, aortic neck angulation, and presence of endoleak at the follow-up.
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Affiliation(s)
- Connie Truong
- Division of Vascular Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Nathan W Kugler
- Division of Vascular Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Peter J Rossi
- Division of Vascular Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Parag J Patel
- Division of Interventional Radiology, Department of Radiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Robert A Hieb
- Division of Interventional Radiology, Department of Radiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Kellie R Brown
- Division of Vascular Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Brian D Lewis
- Division of Vascular Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Gary Seabrook
- Division of Vascular Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Cheong J Lee
- Division of Vascular Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin.
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Tzani A, Doulamis IP, Katsaros I, Martinou E, Schizas D, Economopoulos KP. Mortality after endovascular treatment of infrarenal abdominal aortic aneurysms – the newer the better? VASA 2018; 47:187-196. [PMID: 29334334 DOI: 10.1024/0301-1526/a000685] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Abstract. Although endovascular repair of infrarenal abdominal aortic aneurysms (EVAR) presents a delicate alternative treatment for abdominal aortic aneurysms (AAA) with lower perioperative mortality, its long-term efficacy remains a matter of concern. The purpose of this study was to evaluate the currently reported mortality evidence after EVAR and to examine the possible effect of aneurysm status and the study period on mortality rates. The PubMed and Cochrane bibliographical databases were thoroughly searched for studies reporting on more than 1 000 patients with non-ruptured or ruptured infrarenal AAA, treated with EVAR from August 1991 to September 2016. A total of 10 910 titles/abstracts were retrieved and 121 studies were deemed relevant. Twenty-six studies met the inclusion criteria and reported on 354 500 patients with a mean age of 74.6 years. Almost all of the studies referred to elective EVAR and the mean aneurysm size was 5.58 cm. The most common early complication for elective EVAR was perioperative bleeding (1.9 %), whereas hospital-acquired pneumonia was a major concern in urgent EVAR (28.5 %). Conversion rate to open surgery was 1.2 %. The 30-day all-cause mortality rate was 4.84 % (1.7 % for non- ruptured aneurysms, 33.8 % for ruptured aneurysms).The overall all-cause late mortality in a mean follow-up period of 23.8 months was 19.1 %. The aneurysm-related late mortality rate was 3.4 %. With respect to the time period of patient enrollment, studies reporting on patients recruited before 2006 were found to face more secondary complications and higher late mortality rates than patients enrolled after 2005.The endovascular treatment of large and anatomically suitable infrarenal AAA in selected patients remains a safe alternative to open repair. Our findings demonstrate that newer studies show better long-term outcomes than the older ones, proposing a possible improvement of EVAR techniques and perioperative care and providing encouraging evidence for a wider application of EVAR.
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Affiliation(s)
- Aspasia Tzani
- Surgery Working Group, Society of Junior Doctors, Athens, Greece
| | | | - Ioannis Katsaros
- Surgery Working Group, Society of Junior Doctors, Athens, Greece
| | - Eirini Martinou
- Surgery Working Group, Society of Junior Doctors, Athens, Greece
| | - Dimitrios Schizas
- Surgery Working Group, Society of Junior Doctors, Athens, Greece
- First Department of Surgery, Laiko General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantinos P. Economopoulos
- Surgery Working Group, Society of Junior Doctors, Athens, Greece
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, USA
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Trenner M, Kuehnl A, Reutersberg B, Salvermoser M, Eckstein HH. Nationwide analysis of risk factors for in-hospital mortality in patients undergoing abdominal aortic aneurysm repair. Br J Surg 2018; 105:379-387. [PMID: 29417985 DOI: 10.1002/bjs.10714] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Revised: 07/03/2017] [Accepted: 09/02/2017] [Indexed: 11/09/2022]
Abstract
BACKGROUND There is increasing awareness that women may have worse outcomes following repair of abdominal aortic aneurysm (AAA). The aim of this study was to analyse the association between sex, age and in-hospital mortality after AAA using hospital episode data collected routinely at the nationwide level. METHODS Data were extracted from the nationwide statutory Diagnosis Related Group statistics provided by the German Federal Statistical Office. Patients with a diagnosis of intact (non-ruptured) AAA (ICD-10 GM I71.4) and procedure codes (OPS; 2005-2013) for endovascular aneurysm repair (EVAR) (5-38a.1*) or open aneurysm repair (5-384.5, 5-384.7), treated from 2005 to 2013, were included. A multilevel multivariable regression model was applied to adjust for medical risk (using the Elixhauser co-morbidity score), type of procedure, type of admission, and to account for clustering of patients within centres. The primary outcome was in-hospital mortality. RESULTS Some 84 631 patients were identified, of whom 10 039 (11·9 per cent) were women. Women were significantly older than men at admission (median 74 (i.q.r. 69-80) versus 72 (66-77) years; P < 0·001). EVAR was used less frequently in women (48·1 versus 54·7 per cent; P < 0·001). The in-hospital mortality rate was higher in women, overall (5·0 versus 3·1 per cent; relative risk 1·60, 95 per cent c.i. 1·45 to 1·75), and for EVAR (2·8 versus 1·5 per cent; RR 1·90, 1·60 to 2·30) and open repair (6·8 versus 5·0 per cent; RR 1·36, 1·22 to 1·52). In-hospital mortality increased with age and was highest in patients aged over 80 years. In multivariable regression analysis, female sex (RR 1·20, 1·07 to 1·35) and age per 10-year increase (RR 1·83, 1·73 to 1·95) were independent risk factors for higher in-hospital mortality. CONCLUSION In Germany, women were older when undergoing AAA repair and were less likely to receive EVAR. Mortality rates were higher in older patients and in women, irrespective of the surgical technique used.
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Affiliation(s)
- M Trenner
- Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar and Munich Aortic Centre, Technical University Munich, Munich, Germany
| | - A Kuehnl
- Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar and Munich Aortic Centre, Technical University Munich, Munich, Germany
| | - B Reutersberg
- Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar and Munich Aortic Centre, Technical University Munich, Munich, Germany
| | - M Salvermoser
- Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar and Munich Aortic Centre, Technical University Munich, Munich, Germany
| | - H-H Eckstein
- Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar and Munich Aortic Centre, Technical University Munich, Munich, Germany
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Regarding "Sex differences in mortality and morbidity following repair of intact abdominal aortic aneurysms". J Vasc Surg 2017; 66:1916-1917. [PMID: 29169550 DOI: 10.1016/j.jvs.2017.08.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 08/01/2017] [Indexed: 11/23/2022]
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Prospective cohort 20 years after endovascular treatment for abdominal aortic aneurysm. J Vasc Surg 2017; 67:1102-1109. [PMID: 29074113 DOI: 10.1016/j.jvs.2017.08.063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Accepted: 08/18/2017] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To describe the factors associated with survival 20 years after endovascular treatment of an abdominal aortic aneurysm (AAA) in a single center. METHODS Prospective cohort of asymptomatic patients with an infrarenal aortic aneurysm treated with a bifurcated endovascular graft (Talent) between June 1997 and August 2008. Cox proportional hazard multivariable regression was used for analysis of independent risk factors for survival. Kaplan-Meier curves were done with the long-rank test. P < .05 was considered significant. RESULTS We followed 229 patients, 184 without an endoleak and 45 with an endoleak. Ages ranged between 52 and 89 years, and the mean diameter of the aneurysm was 59.51 ± 14.6 mm. Implantation of the endovascular graft was possible in 99% of the patients. The 30-day mortality rate was 3.4%. In the Cox regression, age <73 years (hazard ratio [HR], 0.42; 95% confidence interval [CI], 0.27-0.64), aneurysm size ≤55 mm (HR, 0.62; 95% CI, 0.40-0.95), male sex (HR, 0.17; 95% CI, 0.05-0.52), American Society of Anesthesiologists surgical risk category I and II vs III and IV (HR, 0.51; 95% CI, 0.34-0.75), and aneurysm size reduction ≤3 mm after treatment (HR, 2.23; 95% CI, 1.11-4.51) were significantly correlated with the survival of the patients followed in this long-term case series. CONCLUSIONS This 20-year prospective cohort included patients with an AAA treated with a bifurcated endovascular graft (Talent) at a university hospital in Brazil. This study supports that sex, age, aneurysm size, aneurysm size reduction, and American Society of Anesthesiologists surgical risk category are significantly correlated with patient survival after endovascular treatment of the AAA.
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Crespy V, Salomon du Mont L, Kaladji A, Bartoli M, Gouëffic Y, Abello N, Magnan PE, Cardon A, Chaillou P, Steinmetz E. Endovascular Treatment of Asymptomatic Abdominal Aortic Aneurysms in Octogenarians: Factors Influencing Long-term Survival. Ann Vasc Surg 2017; 45:199-205. [PMID: 28651997 DOI: 10.1016/j.avsg.2017.05.041] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2016] [Revised: 05/07/2017] [Accepted: 05/09/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND Beyond the age of 80 years, the preventive treatment of an asymptomatic abdominal aortic aneurysm (AAA) has to be decided in light of the life expectancy which it is difficult to evaluate, but it is important to determine who in this population will benefit from it. The objective of our study was to determine the factors influencing short-term mortality and long-term survival in patients aged 80 years and older after the endovascular treatment of AAAs (EVAR). MATERIAL AND METHODS We present a retrospective analysis of the prospective databases of 4 French academic departments of vascular surgery, bringing together the data of all the patients presenting an AAA who were treated by EVAR between 1998 and 2011. Logistic regression and multivariate analysis with a Cox survival model were used to determine the factors influencing perioperative and long-term mortality. The cumulative rate of events for the measurement of survival was calculated with the technique of Kaplan-Meier. RESULTS We treated 345 octogenarians and 339 younger patients. The average follow-up was 40 months. Average survival was 75% at 36 months and 49% at 60 months. There was no evidence of any risk factor influencing mortality at 30 days in the octogenarians. However, chronic kidney disease (odds ratio [OR] = 3.95, P <0.001) and chronic respiratory failure (OR = 2.62, P <0.001) proved to be independent factors of a poor long-term prognosis. CONCLUSIONS The treatment by stent graft in octogenarians is effective in the long term. The presence of an impaired renal function or respiratory failure in this population could put into question the operative indication.
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Affiliation(s)
- Valentin Crespy
- Service de chirurgie cardiovasculaire et thoracique, Cardiovascular and Thoracique Surgery Department, CHU Francois Mitterrand, Dijon, France.
| | - Lucie Salomon du Mont
- Service de chirurgie cardiovasculaire et thoracique, Cardiovascular and Thoracique Surgery Department, CHU Francois Mitterrand, Dijon, France
| | - Adrien Kaladji
- Unité de chirurgie vasculaire, Vascular Surgery Department, CHU Rennes, Rennes, France
| | - Michel Bartoli
- Service de chirurgie vasculaire, Vascular Surgery Department, Hôpital de la Timone, Marseille, France
| | - Yann Gouëffic
- Service de chirurgie vasculaire, Vascular Surgery Department, Institut du Thorax, CHU Nantes, Nantes, France
| | - Nicolas Abello
- Service de chirurgie cardiovasculaire et thoracique, Cardiovascular and Thoracique Surgery Department, CHU Francois Mitterrand, Dijon, France
| | - Pierre-Edouard Magnan
- Service de chirurgie vasculaire, Vascular Surgery Department, Hôpital de la Timone, Marseille, France
| | - Alain Cardon
- Unité de chirurgie vasculaire, Vascular Surgery Department, CHU Rennes, Rennes, France
| | - Philippe Chaillou
- Service de chirurgie vasculaire, Vascular Surgery Department, Institut du Thorax, CHU Nantes, Nantes, France
| | - Eric Steinmetz
- Service de chirurgie cardiovasculaire et thoracique, Cardiovascular and Thoracique Surgery Department, CHU Francois Mitterrand, Dijon, France
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Healy GM, Redmond CE, Gray S, Iacob L, Sheehan S, Dowdall JF, Barry M, Cantwell CP, Brophy DP. Midterm Analysis of Survival and Cause of Death Following Endovascular Abdominal Aortic Aneurysm Repair. Vasc Endovascular Surg 2017. [DOI: 10.1177/1538574417703268] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose: To assess rates of complications, secondary interventions, survival, and cause of death following endovascular abdominal aortic aneurysm (AAA) repair over a 10-year period. Materials and Methods: Single-institution retrospective cohort study of all patients undergoing primary endovascular aortic aneurysm repair (EVAR) between July 2006 and June 2015. The population constituted 175 patients with 163 fusiform and 12 saccular AAAs. Of these, 149 (85%) were male, with mean age 75.4 (±7.1) years. Patients were followed up until June 30, 2016. Cause of death was determined from the national death register. Results: Mean follow-up was 34.4 (±24.4) months. The secondary intervention rate was 9.7%, and there were 4 aneurysm ruptures (0.8% annual incidence). Thirty-day mortality was 0.6%. Survival at 1, 3, and 5 years was 93.1%, 84%, and 64.9%, respectively. Forty-eight patients died during follow-up, 3 secondary to rupture, leading to overall and aneurysm-related death rates of 9.7 and 0.6 per 100 person-years. All other deaths were due to nonaneurysm causes, most commonly cardiovascular (n = 15), pulmonary (n = 13), and malignancy (n = 9). Baseline renal impairment ( P < .001), ischemic heart disease ( P < .05), age greater than 75 years ( P < .05), and urgent/emergency EVAR were associated with inferior long-term survival. Type II endoleak negatively influenced fusiform aneurysm sac regression ( P = .02), but there was no association between survival and occurrence of any complication or secondary intervention. Conclusion: The majority of deaths during medium-term follow-up post-EVAR are due to nonaneurysm-related causes. Survival is determined by the following baseline factors: renal impairment, ischemic heart disease, advanced age, and the presence of a symptomatic/ruptured aneurysm.
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Affiliation(s)
- Gerard M. Healy
- Department of Radiology, St. Vincent’s University Hospital, Dublin, Ireland
| | - Ciaran E. Redmond
- Department of Radiology, St. Vincent’s University Hospital, Dublin, Ireland
| | - Sam Gray
- Department of Radiology, St. Vincent’s University Hospital, Dublin, Ireland
| | - Lucian Iacob
- Department of Vascular Surgery, St. Vincent’s University Hospital, Dublin, Ireland
| | - Stephen Sheehan
- Department of Vascular Surgery, St. Vincent’s University Hospital, Dublin, Ireland
| | - Joseph F. Dowdall
- Department of Vascular Surgery, St. Vincent’s University Hospital, Dublin, Ireland
| | - Mary Barry
- Department of Vascular Surgery, St. Vincent’s University Hospital, Dublin, Ireland
| | - Colin P. Cantwell
- Department of Radiology, St. Vincent’s University Hospital, Dublin, Ireland
| | - David P. Brophy
- Department of Radiology, St. Vincent’s University Hospital, Dublin, Ireland
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Ultee KHJ, Soden PA, Zettervall SL, Darling J, Verhagen HJM, Schermerhorn ML. Conversion from endovascular to open abdominal aortic aneurysm repair. J Vasc Surg 2017; 64:76-82. [PMID: 27345505 DOI: 10.1016/j.jvs.2015.12.055] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Accepted: 12/22/2015] [Indexed: 11/20/2022]
Abstract
BACKGROUND Previous studies have found conflicting results regarding the operative risks associated with conversion to open abdominal aortic aneurysm (AAA) repair after failed endovascular treatment (endovascular aneurysm repair [EVAR]). The purpose of this study was to assess the outcome of patients undergoing a conversion, and compare outcomes with standard open AAA repair and EVAR. In addition, we sought out to identify factors associated with conversion. METHODS All patients undergoing a conversion to open repair, and those undergoing standard EVAR and open repair between 2005 and 2013 were included from the National Surgical Quality Improvement Program. Multivariable logistic regression analysis was used to identify factors associated with conversion, and to assess independent perioperative risks associated with conversion compared with standard AAA repair. Subanalysis for factors associated with conversion was performed among patients additionally included in the more detailed targeted vascular module of the National Surgical Quality Improvement Program. RESULTS A total of 32,164 patients were included, with 300 conversions, 7188 standard open repairs, and 24,676 EVARs. Conversion to open repair was associated with a significantly higher 30-day mortality than standard open repair (10.0% vs 4.2%; odds ratio [OR], 2.4; 95% confidence interval [CI], 1.6-3.6; P < .001), and EVAR (10.0% vs 1.7%; OR, 7.2; 95% CI, 4.8-10.9; P < .001). Conversion surgery was additionally followed by an increased occurrence of any complication (OR, 1.5; 95% CI, 1.2-1.9 [open]; OR, 7.8; 95% CI, 6.1-9.9 [EVAR]). Factors associated with conversion were young age (OR, 1.2 per 10 years decrease; 95% CI, 1.1-1.4), female gender (OR, 1.5; 95% CI, 1.2-2.0), and nonwhite race (OR, 1.8; 95% CI, 1.3-2.6). Conversely, body mass index >30 was negatively associated with (OR, 0.7; 95% CI, 0.5-0.9). Among anatomic characteristics captured in the targeted vascular data set (n = 4555), large aneurysm diameter demonstrated to be strongly associated with conversion (OR, 1.1 per 1 cm increase; 95% CI, 1.03-1.1). CONCLUSIONS Conversion to open repair after failed EVAR is associated with substantially increased perioperative morbidity and mortality compared with standard AAA repair. Factors associated with conversion are large diameter of the aneurysm, young age, female gender, and nonwhite race, whereas obesity is inversely related to conversion surgery.
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Affiliation(s)
- Klaas H J Ultee
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass; Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Peter A Soden
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass
| | - Sara L Zettervall
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass
| | - Jeremy Darling
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass
| | - Hence J M Verhagen
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass.
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Huang Y, Gloviczki P, Duncan AA, Kalra M, Oderich GS, Fleming MD, Harmsen WS, Bower TC. Maximal aortic diameter affects outcome after endovascular repair of abdominal aortic aneurysms. J Vasc Surg 2017; 65:1313-1322.e4. [DOI: 10.1016/j.jvs.2016.10.093] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Accepted: 10/17/2016] [Indexed: 11/30/2022]
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Campesi I, Franconi F, Seghieri G, Meloni M. Sex-gender-related therapeutic approaches for cardiovascular complications associated with diabetes. Pharmacol Res 2017; 119:195-207. [PMID: 28189784 DOI: 10.1016/j.phrs.2017.01.023] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Revised: 12/14/2016] [Accepted: 01/23/2017] [Indexed: 12/14/2022]
Abstract
Diabetes is a chronic disease associated with micro- and macrovascular complications and is a well-established risk factor for cardiovascular disease. Cardiovascular complications associated with diabetes are among the most important causes of death in diabetic patients. Interestingly, several sex-gender differences have been reported to significantly impact in the pathophysiology of diabetes. In particular, sex-gender differences have been reported to affect diabetes epidemiology, risk factors, as well as cardiovascular complications associated with diabetes. This suggests that different therapeutic approaches are needed for managing diabetes-associated cardiovascular complications in men and women. In this review, we will discuss about the sex-gender differences that are known to impact on diabetes, mainly focusing on the cardiovascular complications associated with the disease. We will then discuss the therapeutic approaches for managing diabetes-associated cardiovascular complications and how differences in sex-gender can influence the existing therapeutic approaches.
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Affiliation(s)
- Ilaria Campesi
- Department of Biomedical Sciences, University of Sassari, Sassari, Italy.
| | - Flavia Franconi
- Department of Biomedical Sciences, University of Sassari, Sassari, Italy; Dipartimento Politiche della Persona, Regione Basilicata, Italy.
| | | | - Marco Meloni
- BHF Centre for Cardiovascular Science, Queen's Medical Research Institute, University of Edinburgh, UK.
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Caulley L, Johnson-Obaseki S, Luo L, Javidnia H. Risk factors for postoperative complications in total thyroidectomy: A retrospective, risk-adjusted analysis from the National Surgical Quality Improvement Program. Medicine (Baltimore) 2017; 96:e5752. [PMID: 28151852 PMCID: PMC5293415 DOI: 10.1097/md.0000000000005752] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Thyroid cancer incidence is increasing, and with it, an increase in total thyroidectomy. There are limited studies comparing outcomes in total thyroidectomy performed in the inpatient versus outpatient setting.The objective of this study was to perform a comparative analysis of risk factors and outcomes of postoperative morbidity and mortality in total thyroidectomy performed as an inpatient versus outpatient surgery.Retrospective cohort study of data from the 2005 to 2014 multi-institutional, risk-adjusted American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. A multivariate regression model with corresponding odds ratios and 95% confidence intervals was used to determine 30-day morbidity and mortality after total thyroidectomies, and also risk factors of postoperative outcomes.From 2005 to 2014, 40,025 total thyroidectomies were performed (48.5% inpatient, 51.5% outpatient). The 30-day complication rate for all total thyroidectomies was 7.74%. Multivariate logistic regression analysis was performed to control for potential confounding variables. Preoperative factors that affected complications rates for inpatient thyroidectomies included: age ≥70, non-Caucasian race, dependent functional status, history of congestive heart failure, smoking history, bleeding disorder, wound infection, and preoperative sepsis (P < 0.05). In addition, preoperative factors affecting complications in thyroidectomy performed as an outpatient surgery included malignant thyroid pathology (P 0.05).We identified a subset of preoperative conditions that affect risk of complications after total thyroidectomy. Recommendations for patient selection for outpatient total thyroidectomies should be modified to account for pre-existing conditions that increase the risk of postoperative morbidity.
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Affiliation(s)
- Lisa Caulley
- Department of Otolaryngology-Head and Neck Surgery, University of Ottawa
- The Ottawa Hospital
| | | | - Lindy Luo
- Department of Undergraduate Medical Education, University of Ottawa, Ottawa, Ontario, Canada
| | - Hedyeh Javidnia
- Department of Otolaryngology-Head and Neck Surgery, University of Ottawa
- The Ottawa Hospital
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Deery SE, Soden PA, Zettervall SL, Shean KE, Bodewes TCF, Pothof AB, Lo RC, Schermerhorn ML. Sex differences in mortality and morbidity following repair of intact abdominal aortic aneurysms. J Vasc Surg 2016; 65:1006-1013. [PMID: 27986477 DOI: 10.1016/j.jvs.2016.08.100] [Citation(s) in RCA: 98] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Accepted: 08/07/2016] [Indexed: 01/15/2023]
Abstract
OBJECTIVE Medicare studies have shown increased perioperative mortality in women compared with men following endovascular and open abdominal aortic aneurysm (AAA) repair. However, a recent regional study of high-volume centers, adjusting for anatomy but limited in sample size, did not show sex to be predictive of worse outcomes. This study aimed to evaluate sex differences after intact AAA repair in a national clinical registry. METHODS The targeted vascular module of the National Surgical Quality Improvement Program was queried to identify patients undergoing endovascular aneurysm repair (EVAR) or open repair for intact, infrarenal AAA from 2011 to 2014. Univariate analysis was performed using the Fisher exact test and Mann-Whitney test. Multivariable logistic regression was used to account for differences in comorbidities, aneurysm details, and operative characteristics. RESULTS We identified 6611 patients (19% women) who underwent intact AAA repair (87% EVAR; 83% women vs 88% men; P < .001). Women were older (median age, 76 vs 73 years; P < .001), had smaller aneurysms (median, 5.4 vs 5.5 cm; P < .001), and had more chronic obstructive pulmonary disease (22% vs 17%; P < .001). Among patients undergoing EVAR, women had longer operative times (median, 138 [interquartile range, 103-170] vs 131 [106-181] minutes; P < .01) and more often underwent renal (6.3% vs 4.1%; P < .01) and lower extremity (6.6% vs 3.8%; P < .01) revascularization. After open repair, women had shorter operative time (215 [177-304] vs 226 [165-264] minutes; P = .02), but women less frequently underwent lower extremity revascularization (3.1% vs 8.2%; P = .03). Thirty-day mortality was higher in women after EVAR (3.2% vs 1.2%; P < .001) and open repair (8.0% vs 4.0%; P = .04). After adjusting for repair type, age, aneurysm diameter, and comorbidities, female sex was independently associated with mortality (odds ratio [OR], 1.7; 95% confidence interval [CI], 1.1-2.6; P = .02) and major complications (OR, 1.4; CI, 1.1-1.7; P < .01) after intact AAA repair. However, after adjusting for aortic size index rather than for aortic diameter, the association between female sex and mortality (OR, 1.5; CI, 0.98-2.4; P = .06) and major complications (OR, 1.1; CI, 0.9-1.4; P = .24) was reduced. CONCLUSIONS Women were at higher risk for 30-day death and major complications after intact AAA repair. Some of this disparity may be explained by differences in aortic size index, which should be further evaluated to determine the ideal threshold for repair.
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Affiliation(s)
- Sarah E Deery
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass; Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Peter A Soden
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Sara L Zettervall
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Katie E Shean
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Thomas C F Bodewes
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Alexander B Pothof
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Ruby C Lo
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass.
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Machado R, Teixeira G, Oliveira P, Loureiro L, Pereira C, Almeida R. Endovascular Abdominal Aneurysm Repair in Women: What are the Differences Between the Genders? Braz J Cardiovasc Surg 2016; 31:232-238. [PMID: 27737406 PMCID: PMC5062709 DOI: 10.5935/1678-9741.20160047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 07/04/2016] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION: Abdominal aortic aneurysm has a lower incidence in the female population, but
a higher complication rate. It was been hypothesized that some anatomical
differences of abdominal aortic aneurysm in women could be responsible for
that. We proposed to analyze our data to understand the differences in the
clinical and anatomical characteristics and the outcomes of patients
undergoing endovascular aneurysm repair, according to gender. METHODS: A retrospective analysis of patients undergoing endovascular aneurysm repair
between 2001-2013 was performed. Patients were divided according gender and
evaluated regarding age, atherosclerotic risk factors, aneurysm anatomic
features, endograft type, anesthesic risk classification, length of stay,
reinterventions and mortality. Two statistical studies were performed, first
comparing women and men (Group A) and a second one comparing women and men,
adjusted by age (Group B). RESULTS: Of the 171 patients, only 5.8% (n=10) were females. Women were older
(P<0.05) and the number of women with no
atherosclerotic risk factor was significantly higher. The comparison
adjusted by age revealed women with statistically less smoking history, less
cerebrovascular disease and ischemic heart disease. Women had a trend to
more complex anatomy, with more iliac intern artery aneurysms, larger
aneurysm diameter and neck angulations statistically more elevated. No other
variables were statistically different between age groups, neither
reintervention nor mortality rates. CONCLUSION: Our study showed a clear difference in the clinical characteristics of women.
The female population was statistically older, and when compared with men
adjusted by age, had less atherosclerotic risk factors and less target organ
disease. Women showed a more complex anatomy but with the same outcomes.
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Affiliation(s)
- Rui Machado
- Hospital de Santo António - Centro Hospitalar do Porto, Porto, Portugal.,Instituto de Ciências Biomédicas Abel Salazar (ICBAS), Porto, Portugal
| | - Gabriela Teixeira
- Hospital de Santo António - Centro Hospitalar do Porto, Porto, Portugal
| | - Pedro Oliveira
- Instituto de Ciências Biomédicas Abel Salazar (ICBAS), Porto, Portugal
| | - Luís Loureiro
- Hospital de Santo António - Centro Hospitalar do Porto, Porto, Portugal
| | - Carlos Pereira
- Hospital de Santo António - Centro Hospitalar do Porto, Porto, Portugal
| | - Rui Almeida
- Hospital de Santo António - Centro Hospitalar do Porto, Porto, Portugal.,Instituto de Ciências Biomédicas Abel Salazar (ICBAS), Porto, Portugal
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Lowry D, Singh J, Mytton J, Tiwari A. Sex-related Outcome Inequalities in Endovascular Aneurysm Repair. Eur J Vasc Endovasc Surg 2016; 52:518-525. [DOI: 10.1016/j.ejvs.2016.07.083] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 07/20/2016] [Indexed: 11/25/2022]
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Soden PA, Zettervall SL, Ultee KHJ, Darling JD, McCallum JC, Hamdan AD, Wyers MC, Schermerhorn ML. Patient selection and perioperative outcomes are similar between targeted and nontargeted hospitals (in the National Surgical Quality Improvement Program) for abdominal aortic aneurysm repair. J Vasc Surg 2016; 65:362-371. [PMID: 27462004 DOI: 10.1016/j.jvs.2016.04.066] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 04/29/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVE The targeted vascular module in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) consists of self-selected hospitals that choose to collect extra clinical details for better risk adjustment and improved procedure-specific outcomes. The purpose of this study was to compare patient selection and outcomes between targeted and nontargeted hospitals in the NSQIP regarding the operative management of abdominal aortic aneurysm (AAA). METHODS We identified all patients who underwent endovascular aneurysm repair (EVAR) or open AAA repair from 2011 to 2013 and compared cases by whether the operation took place in a targeted or nontargeted hospital. EVAR and open repair as well as intact and ruptured aneurysms were evaluated separately. Only variables contained in both modules were used to evaluate rupture status and operation type. All thoracoabdominal aneurysms were excluded. Univariate analysis was performed for intact and ruptured EVAR and open repair grouped by complexity, defined as visceral involvement in open repair and a compilation of concomitant procedures for EVAR. Multivariable models were developed to identify effect of hospital type on mortality. RESULTS There were 17,651 AAA repairs identified. After exclusion of aneurysms involving the thoracic aorta (n = 352), there were 1600 open AAA repairs at targeted hospitals (21% ruptured) and 2725 at nontargeted hospitals (19% ruptured) and 4986 EVARs performed at targeted hospitals (6.7% ruptured) and 7988 at nontargeted hospitals (5.2% ruptured). There was no significant difference in 30-day mortality rates between targeted and nontargeted hospitals for intact aneurysms (EVAR noncomplex, 1.8% vs 1.4% [P = .07]; open repair noncomplex, 4.2% vs 4.5% [P = .7]; EVAR complex, 5.0% vs 3.2% [P = .3]; open repair complex, 8.0% vs 6.0% [P = .2]). For ruptured aneurysms, again there was no difference in mortality between the targeted and nontargeted hospitals (EVAR noncomplex, 23% vs 25% [P = .4]; open repair noncomplex, 38% vs 34% [P = .2]; EVAR complex, 29% vs 33% [P = 1.0]; open repair complex, 27% vs 41% [P = .09]). Multivariable analysis further demonstrated that having an operation at a targeted vs nontargeted hospital had no impact on mortality for both intact and ruptured aneurysms (odds ratio, 1.1 [0.9-1.4] and 1.0 [0.8-1.3], respectively). CONCLUSIONS This analysis highlights the similarities between targeted and nontargeted hospitals within the NSQIP for AAA operative management and suggests that data from the targeted NSQIP, in terms of AAA management, are generalizable to all NSQIP hospitals.
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Affiliation(s)
- Peter A Soden
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Sara L Zettervall
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass; Division of Surgery, George Washington University, Washington, D.C
| | - Klaas H J Ultee
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass; Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Jeremy D Darling
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - John C McCallum
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Allen D Hamdan
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Mark C Wyers
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.
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Zhu Y, Wang B, Meng Q, Liu J, Zhai S, He J. Long-term efficacy of endovascular vs open surgical repair for complicated type-B aortic dissection: a single-center retrospective study and meta-analysis. ACTA ACUST UNITED AC 2016; 49:e5194. [PMID: 27254661 PMCID: PMC4932819 DOI: 10.1590/1414-431x20165194] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 04/08/2016] [Indexed: 11/22/2022]
Abstract
This study aimed to evaluate the long-term survival and risk factors of traditional
open surgical repair (OSR) vs thoracic endovascular aneurysm repair
(TEVAR) for complicated type-B aortic dissection (TBAD). A total of 118 inpatients
(45 OSR vs 73 TEVAR) with TBAD were enrolled from January 2004 to
January 2015. Kaplan-Meier curves and Cox proportional hazards analysis were
performed to identify the long-term survival rate and independent predictors of
survival, respectively. Meta-analysis was used to further explore the long-term
efficacy of OSR and TEVAR in the eight included studies using Review Manager 5.2
software. An overall 10-year survival rate of 41.9% was found, and it was similar in
the two groups (56.7% OSR vs 26.1% TEVAR; log-rank P=0.953). The
risk factors of long-term survival were refractory hypertension (OR=11.1;
95%CI=1.428-86.372; P=0.021] and preoperative aortic diameter >55
mm (OR=4.5; 95%CI=1.842-11.346; P=0.001). Long-term survival rate
did not differ significantly between OSR and TEVAR (hazard ratio=0.87;
95%CI=0.52-1.47; P=0.61). Compared with OSR, TEVAR did not show
long-term advantages for patients with TBAD. Refractory hypertension and total aortic
diameter >55 mm can be used to predict the long-term survival of TBAD in the
Chinese Han population.
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Affiliation(s)
- Y Zhu
- Department of Cardiothoracic Surgery, Kaifeng Central Hospital, Kaifeng, China
| | - B Wang
- Department of Cardiothoracic Surgery, Kaifeng Central Hospital, Kaifeng, China
| | - Q Meng
- Department of Cardiothoracic Surgery, Kaifeng Central Hospital, Kaifeng, China
| | - J Liu
- Department of Cardiothoracic Surgery, Kaifeng Central Hospital, Kaifeng, China
| | - S Zhai
- Department of Cardiothoracic Surgery, Henan Provincial People's Hospital, Zhengzhou, China
| | - J He
- Department of Cardiothoracic Surgery, Kaifeng Central Hospital, Kaifeng, China
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Lo RC, Schermerhorn ML. Abdominal aortic aneurysms in women. J Vasc Surg 2016; 63:839-44. [PMID: 26747679 PMCID: PMC4769685 DOI: 10.1016/j.jvs.2015.10.087] [Citation(s) in RCA: 100] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Accepted: 10/16/2015] [Indexed: 01/15/2023]
Abstract
Abdominal aortic aneurysm (AAA) has long been recognized as a condition predominantly affecting males, with sex-associated differences described for almost every aspect of the disease from pathophysiology and epidemiology to morbidity and mortality. Women are generally spared from AAA formation by the immunomodulating effects of estrogen, but once they develop, the natural history of AAAs in women appears to be more aggressive, with more rapid expansion, a higher tendency to rupture at smaller diameters, and higher mortality following rupture. However, simply repairing AAAs at smaller diameters in women is a debatable solution, as even elective endovascular AAA repair is fraught with higher morbidity and mortality in women compared to men. The goal of this review is to summarize what is currently known about the effect of gender on AAA presentation, treatment, and outcomes. Additionally, we aim to review current controversies over screening recommendations and threshold for repair in women.
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Affiliation(s)
- Ruby C Lo
- Beth Israel Deaconess Medical Center, Boston, Mass
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Hammond CJ, Shah AH, Snoddon A, Patel JV, Scott DJA. Mortality and Rates of Secondary Intervention After EVAR in an Unselected Population: Influence of Simple Clinical Categories and Implications for Surveillance. Cardiovasc Intervent Radiol 2016; 39:815-23. [DOI: 10.1007/s00270-016-1303-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 02/05/2016] [Indexed: 12/01/2022]
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