Predictors of in-hospital adverse events after endovascular aortic aneurysm repair

Predictors of 30-Day Postoperative Outcome after Elective Endovascular Abdominal Aortic Aneurysm Repair: A Tertiary Referral Center Experience

BACKGROUND

We evaluated the 30-day postoperative outcome after elective endovascular aneurysm repair (EVAR) and the possible predictors for the 30-day postoperative outcome.

MATERIALS

Demographics, medical history, laboratory values, intensive care unit (ICU) admission and 30-day complications classified as major (major adverse cardiovascular events (MACEs), acute kidney injury (AKI) and death of any cause) and minor (postimplantation syndrome (PIS), postoperative delirium (POD), urinary tract infection (UTI) and technical graft failure) were documented (March 2016 to February 2019).

RESULTS

We included 322 patients. The majority were managed under general anesthesia (83%) with femoral cutdown (98.1%). Overall, 121 (37.5%) complications, mostly minor (n = 103, 31.9%), were recorded. In total, 11 patients (3.4%) developed MACEs, 5 (1.6%) experienced AKI and 2 (0.6%) died in the ICU. Moreover, 77 patients (23.9%) suffered from PIS, 11 from POD, 11 from UTI and 4 from technical graft failure. The multivariate logistic regression analysis revealed that aneurysm diameter (p = 0.01) and past smoking (p = 0.003) were predictors for complications. PAD was an independent predictor of MACEs (p = 0.003), preoperative neutrophil to lymphocyte ratio (NLR) of AKI (p = 0.003) and past smoking of PIS (p = 0.008), respectively.

CONCLUSIONS

Our study showed that the 30-day morbidity after EVAR exceeded 35%. However, the majority of complications were minor, and the associated mortality was low. Aneurysm diameter and past smoking were independent predictors for postoperative outcome.

Incidence, predictors, and prognostic impact of in-hospital serious adverse events in patients ≥75 years of age undergoing elective endovascular aneurysm repair

BACKGROUND

This study sought to identify the factors associated with the occurrence of in-hospital serious adverse events after elective endovascular aortic repair (EVAR) in older patients within the Global Registry for Endovascular Aortic Treatment.

METHODS

Consecutive patients ages ≥75 years who received GORE EXCLUDER AAA Endoprosthesis (W.L. Gore & Associates, Inc, Flagstaff, AZ) for elective EVAR. Based on the age at index elective EVAR, patients were categorized into 3 groups for subsequent analyses: those ages 75 to 79, 80 to 84, and ≥85 years. The primary end points for this study were the incidence of serious adverse events and all-cause mortality. In-hospital complications were defined according to the International Organization for Standardization 14155 standard (https://www.iso.org/standard/71690.html) and considered serious adverse events if they led to any of the following: (1) a life-threatening illness or injury, (2) a permanent impairment of a body structure or a body function, (3) in-patient or prolonged hospitalization, or (4) medical or surgical intervention to prevent life-threatening illness or injury or permanent impairment to a body structure or a body function.

RESULTS

Overall, 1,333 older patients (ages 75-79: n = 601; 80-84: n = 474; and ≥85: n = 258) underwent elective EVAR in the Global Registry for Endovascular Aortic Treatment data set and were included in the present analysis. In total, 12 patients (0.9%) died perioperatively, and 103 patients (7.7%) experienced ≥1 in-hospital serious adverse event, with 18 patients (1.3%) experiencing >1 in-hospital complications. No significant differences were seen between the age groups in the rates of in-hospital serious adverse events (7.3% vs 8.2% vs 7.8%; P = .86). In logistic regression analysis, a history of chronic obstructive pulmonary disease (odds ratio = 2.014; 95% confidence interval, 1.215-3.340; P = .006) and prior requirement for dialysis (odds ratio = 4.655; 95% confidence interval, 1.087-19.928; P = .038) resulted as predictors for occurrence of in-hospital serious adverse events. In the whole cohort, the 5-year survival was 63% for patients who did not experience any in-hospital serious adverse events compared with 51% for those who experienced any complications (P = .003). Using multivariable Cox proportional hazards models, it was found that the occurrence of in-hospital serious adverse events (hazard ratio = 6.2; 95% confidence interval, 1.8-21.317; P = .003) and being underweight (hazard ratio = 7.0; 95% confidence interval, 1.371-35.783; P = .019) were the only independent predictors of death in ≤30 days from the initial intervention. Although age did not independently affect the risk for all-cause mortality in ≤180 days after the initial intervention, increasing age was associated with a higher risk for long-term death (ie, ≥181 days from index elective EVAR) in the multivariable analysis (ages 75-79: hazard ratio = 0.379; 95% confidence interval, 0.281-0.512; P < .001; and 80-84: hazard ratio = 0.562; 95% confidence interval, 0.419-0.754; P < .001).

CONCLUSION

After elective EVAR in older patients (ie, ≥75 years), the occurrence of in-hospital serious adverse events appears to increase the risk of death, particularly in ≤180 days after the initial elective EVAR intervention, and might be related to patient baseline characteristics, including history of pulmonary and renal disease.

Evaluating Social Determinants of Health Variables in Advanced Analytic and Artificial Intelligence Models for Cardiovascular Disease Risk and Outcomes: A Targeted Review

Introduction/Purpose

Predictive models incorporating relevant clinical and social features can provide meaningful insights into complex interrelated mechanisms of cardiovascular disease (CVD) risk and progression and the influence of environmental exposures on adverse outcomes. The purpose of this targeted review (2018-2019) was to examine the extent to which present-day advanced analytics, artificial intelligence, and machine learning models include relevant variables to address potential biases that inform care, treatment, resource allocation, and management of patients with CVD.

Methods

PubMed literature was searched using the prespecified inclusion and exclusion criteria to identify and critically evaluate primary studies published in English that reported on predictive models for CVD, associated risks, progression, and outcomes in the general adult population in North America. Studies were then assessed for inclusion of relevant social variables in the model construction. Two independent reviewers screened articles for eligibility. Primary and secondary independent reviewers extracted information from each full-text article for analysis. Disagreements were resolved with a third reviewer and iterative screening rounds to establish consensus. Cohen's kappa was used to determine interrater reliability.

Results

The review yielded 533 unique records where 35 met the inclusion criteria. Studies used advanced statistical and machine learning methods to predict CVD risk (10, 29%), mortality (19, 54%), survival (7, 20%), complication (10, 29%), disease progression (6, 17%), functional outcomes (4, 11%), and disposition (2, 6%). Most studies incorporated age (34, 97%), sex (34, 97%), comorbid conditions (32, 91%), and behavioral risk factor (28, 80%) variables. Race or ethnicity (23, 66%) and social variables, such as education (3, 9%) were less frequently observed.

Conclusions

Predictive models should adjust for race and social predictor variables, where relevant, to improve model accuracy and to inform more equitable interventions and decision making.

Impact of an emergency endovascular aneurysm repair protocol on 30-day ruptured abdominal aortic aneurysm mortality

OBJECTIVE

To characterize the longstanding impact of an emergency endovascular aneurysm repair (EVAR) protocol for ruptured abdominal aortic aneurysm (rAAA) on 30-day mortality.

METHODS

All adult patients with an rAAA who underwent a surgical or endovascular intervention at a tertiary care center between March 2001 and December 2018 were evaluated. An emergency EVAR protocol was introduced in January 2004. The primary outcome was 30-day mortality, which was calculated using risk-adjusted logistic regression for the preprotocol and postprotocol periods. A risk-adjusted cumulative sum analysis examined changes in 30-day mortality after protocol implementation.

RESULTS

We identified 376 patients with rAAA between 2001 and 2018 (75 preprotocol and 301 postprotocol), with a decreasing incidence of rAAA during the study period. The introduction of the protocol in 2004 was associated with increased EVAR use (63.6% vs 6.7%; P < .001). Patients managed according to the protocol were more frequently unstable (systolic blood pressure [SBP] of ≤80 mm Hg, 46.5% postprotocol vs 22.7% preprotocol; P < 0.001), with a lower average SBP (87.4 mm Hg postprotocol vs 106 mm Hg preprotocol; P < .001) and worse renal function (estimated glomerular filtration rate 61.5 mL/min postprotocol vs 83.2 mL/min preprotocol; P < .001). The risk-adjusted 30-day mortality was 23.2% with the emergency EVAR protocol, versus 35.8% preprotocol (P = .0727). A subgroup analysis demonstrated improved the 30-day mortality for unstable patients (SBP of ≤80 mm Hg) at 38.0% (vs 62.4% preprotocol introduction; P = .0190). A cumulative sum analysis demonstrated worse than expected mortality outcomes in the preprotocol period, and stability of surgical performance over 15 years after protocol introduction.

CONCLUSIONS

On reflection of a 17-year experience with EVAR for rAAA, the implementation of an emergency EVAR protocol demonstrated stable surgical performance for all patients with an rAAA and evidence of improved 30-day mortality for unstable patients with an rAAA. Since the protocol introduction, EVAR has become a mainstay intervention and, despite an increase in comorbid patients, the overall incidence of rAAA is declining. EVAR should be considered the first-line intervention for the appropriate patient unstable with an rAAA.

Association of abdominal aortic aneurysm diameter indexed to patient height with symptomatic presentation and mortality

BACKGROUND

The current guidelines have recommended repair of abdominal aortic aneurysms (AAAs) according to the maximal AAA diameter and/or its growth rate. However, many studies have suggested that the AAA diameter alone is not sufficient to predict the risk of rupture or symptomatic presentation. Several investigators have attempted to relate the AAA diameter to the body surface area in predicting for rupture. However, these calculations have not resulted in conclusive evidence. We sought in the present analysis to introduce a novel diameter-to-height index (DHI) and test its utility in predicting for symptomatic presentations, including rupture and 30-day and 5-year mortality.

METHODS

The Vascular Quality Initiative database (2003-2020) was used to identify patients who had undergone open or endovascular AAA repair. The DHI was defined as the AAA diameter in centimeters divided by the height in centimeters, yielding a score of 1 to 10. Multivariable logistic regression analysis was performed to assess the risk of symptomatic presentation, including rupture and 30-day mortality. Receiver operating characteristic curves were plotted, and survival analysis techniques were used to determine the hazard of 5-year mortality.

RESULTS

A total of 64,595 patients were identified, of whom, 16.3% had presented with symptomatic AAAs, including rupture. Endovascular AAA repair was performed for 69.8% of the symptomatic AAAs and 84.3% of asymptomatic AAAs (P < .001). The symptomatic group were more likely to be women (24.6% vs 19.8%; P < .001) and Black (7.81% vs 4.44%; P < .001). The mean DHI was higher in the symptomatic group than in the asymptomatic group (mean DHI, 3.92 ± 1.1 vs 3.24 ± 0.7; P < .001). The adjusted odds of a symptomatic presentation increased with an increasing DHI (adjusted odds ratio [aOR], 1.70; 95% confidence interval [CI], 1.59-1.83; P < .001). Active smoking increased the risk of a symptomatic presentation (aOR, 1.38; 95% CI, 1.28-1.51; P < .001). However, the use of preoperative statins and beta-blockers significantly reduced the odds of a symptomatic presentation (aOR, 0.58; 95% CI, 0.53-0.64; P < .001; and aOR, 0.76; 95% CI, 0.69-0.84; P < .001), respectively. Compared with the AAA diameter, the receiver operating characteristic curve for the DHI to predict for symptomatic status was slightly, but significantly, higher (aOR, 0.702; 95% CI, 0.695-0.708; vs aOR, 0.695; 95% CI, 0.688-0.701; P < .001). The DHI increment was associated with a 1.08 greater odds of 30-day mortality (aOR, 1.08; 95% CI, 1.01-1.15; P < .001) for those with symptomatic AAAs. Similarly, the hazard of 5-year mortality was increased with an increasing DHI (adjusted hazard ratio, 1.20; 95% CI, 1.13-1.29; P < .001) only for those with asymptomatic AAAs.

CONCLUSIONS

The DHI is a simple tool that could be more effective than the AAA diameter in predicting for symptomatic presentations. The DHI varied by sex and race, which could collectively help to provide an individualized prognosis. The DHI can additionally predict the 5-year mortality after AAA repair for those with asymptomatic AAAs only. However, the odds of 30-day mortality remained similar in both groups.

Risk assessment in aortic aneurysm repair by medical specialists versus the American College of Surgeons National Surgical Quality Improvement Program risk calculator outcomes

Objective

The aim of this online clinical vignette-based survey study was to compare risk assessments by vascular surgeons, anaesthesiologists and interventional radiologists involved in treating patients with aortic aneurysms in the Netherlands with the NSQIP risk calculator outcomes.

Methods

Participants, recruited using purposive sampling, provided their estimation of the likelihood of postoperative complications and events following aortic surgery in five fictional cases. These cases were subsequently scored using the NSQIP calculator. The risk assessments were statistically analysed using the ANOVA and student t-test.

Results

All participating specialists i.e. twelve vascular surgeons, ten interventional radiologists and ten anaesthesiologists completed the survey. In the vast majority of outcomes and vignettes, no significant differences were found between various specialists, whereas significant differences were found between the NSQIP risk calculator outcomes and the combined risk assessments of the specialists. Overall, specialist risk assessments differ from the NSQIP, but neither particularly higher nor lower compared to the risk calculator.

Conclusions

Risk assessment by vascular surgeons, anaesthesiologists and interventional radiologists differs significantly with NSQIP risk calculator outcomes, within the framework of both endovascular and open aortic aneurysm repair. Based on these results, implementing the NSQIP risk calculator in preoperative workup could be of added value in both patient planning as well as adequately informing patients for obtaining consent.

Aneurysms and dissections - What is new in the literature of 2019/2020 - a European Society of Vascular Medicine annual review

More than 6,000 publications were found in PubMed concerning aneurysms and dissections, including those Epub ahead of print in 2019, printed in 2020. Among those publications 327 were selected and considered of particular interest.