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Mehta A, Rastogi V, Yadavalli SD, Canta O, Giles K, Scali S, O'Donnell TFX, Patel VI, Schermerhorn ML. Long-term costs to Medicare associated with endovascular and open repairs of infrarenal and complex abdominal aortic aneurysms. J Vasc Surg 2024; 80:98-106. [PMID: 38490605 DOI: 10.1016/j.jvs.2024.03.017] [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: 10/17/2023] [Revised: 03/04/2024] [Accepted: 03/07/2024] [Indexed: 03/17/2024]
Abstract
OBJECTIVE The vast majority of patients with abdominal aortic aneurysms (AAAs) undergoing repairs receive endovascular interventions (EVARs) instead of open operations (OARs). Although EVARs have better short-term outcomes, OARs have improved longer-term durability and require less radiographic follow-up and monitoring, which may have significant implications on health care economics surrounding provision of AAA care nationally. Herein, we compared costs associated with EVAR and OAR of both infrarenal and complex AAAs. METHODS We examined patients undergoing index elective EVARs or OARs of infrarenal and complex AAAs in the 2014-2019 Vascular Quality Initiative-Vascular Implant Surveillance and Interventional Outcomes Network (VQI-VISION) dataset. We defined overall costs as the aggregated longitudinal costs associated with: (1) the index surgery; (2) reinterventions; and (3) imaging tests. We evaluated overall costs up to 5 years after infrarenal AAA repair and 3 years for complex AAA repair. Multivariable regressions adjusted for case-mix when evaluating cost differences between EVARs vs OARs. RESULTS We identified 23,746 infrarenal AAA repairs (8.7% OAR, 91% EVAR) and 2279 complex AAA repairs (69% OAR, 31% EVAR). In both cohorts, patients undergoing EVARs were more likely to be older and have more comorbidities. The cost for the index procedure for EVARs relative to OARs was lower for infrarenal AAAs ($32,440 vs $37,488; P < .01) but higher among complex AAAs ($48,870 vs $44,530; P < .01). EVARs had higher annual imaging and reintervention costs during each of the 5 postoperative years for infrarenal aneurysms and the 3 postoperative years for complex aneurysms. Among patients undergoing infrarenal AAA repairs who survived 5 years, the total 5-year cost of EVARs was similar to that of OARs ($35,858 vs $34,212; -$223 [95% confidence interval (CI), -$3042 to $2596]). For complex AAA repairs, the total cost at 3 years of EVARs was greater than OARs ($64,492 vs $42,212; +$9860 [95% CI, $5835-$13,885]). For patients receiving EVARs for complex aneurysms, physician-modified endovascular grafts had higher index procedure costs ($55,835 vs $47,064; P < .01) although similar total costs on adjusted analyses (+$1856 [95% CI, -$7997 to $11,710]; P = .70) relative to Zenith fenestrated endovascular grafts among those that were alive at 3 years. CONCLUSIONS Longer-term costs associated with EVARs are lower for infrarenal AAAs but higher for complex AAAs relative to OARs, driven by reintervention and imaging costs. Further analyses to characterize the financial viability of EVARs for both infrarenal and complex AAAs should evaluate hospital margins and anticipated changes in costs of devices.
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Affiliation(s)
- Ambar Mehta
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Aortic Center, New York-Presbyterian Columbia University Irving Medical Center, New York, NY; Department of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Vinamr Rastogi
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Sai Divya Yadavalli
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Olga Canta
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Kristina Giles
- Department of Vascular Surgery and Endovascular Therapy, Main Medical Center, Portland, ME
| | - Salvatore Scali
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL
| | - Thomas F X O'Donnell
- Aortic Center, New York-Presbyterian Columbia University Irving Medical Center, New York, NY
| | - Virendra I Patel
- Aortic Center, New York-Presbyterian Columbia University Irving Medical Center, New York, NY
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
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Talvitie M, Jonsson M, Roy J, Hultgren R. Association of women-specific size threshold and mortality in elective abdominal aortic aneurysm repair. Br J Surg 2024; 111:znad376. [PMID: 37963191 PMCID: PMC10776526 DOI: 10.1093/bjs/znad376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 08/17/2023] [Accepted: 10/22/2023] [Indexed: 11/16/2023]
Abstract
BACKGROUND It is unclear whether women derive mortality benefit from early repair of abdominal aortic aneurysms (AAA). The aim of this study was to compare short- and mid-term mortality for women treated at small versus large diameters. METHOD Women receiving elective repair of AAA at small (49-54 mm) and large (≥55 mm) diameters from 2008 to 2022 were extracted from the Swedish National Registry for Vascular Surgery (n = 1642 women). The effect of diameter on 90-day, 1- and 3-year mortality was studied in logistic regression and propensity score models. Age, co-morbidities, smoking and repair modality were considered as confounders. Men (n = 9047) were analysed in parallel. RESULTS Some 1642 women were analysed, of whom 34% underwent repair at small diameters (versus 52% of men). Women with small (versus large) AAAs were younger (73 versus 75 years, P < 0.001), and 63% of women in both size groups had endovascular repairs (P = 0.120). Mortality was 3.5% (90 days), 7.1% (1 year) and 15.8% (3 years), with no differences between the size strata. There was no consistent association between AAA size and mortality in multivariable models. Sex differences in mortality were almost entirely due to mortality in younger-than-average women versus men (3-year mortality: small AAAs 11.1% versus 7.3%, P < 0.030, or large 14.4% versus 10.7%, P < 0.038). CONCLUSION Mortality in women is high and unaffected by AAA size at repair. The optimal threshold for women remains undefined. The higher rupture risk in women should not automatically translate into a lower, women-specific threshold.
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Affiliation(s)
- Mareia Talvitie
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Magnus Jonsson
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Joy Roy
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Rebecka Hultgren
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden
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Mehta A, Patel P, Elmously A, Iannuzzi J, Garg K, Siracuse J, Takayama H, Schermerhorn ML, O'Donnell TFX, Patel VI. Low-volume surgeons can have better outcomes at certain hospital settings for open abdominal aortic repairs. J Vasc Surg 2023; 78:638-646. [PMID: 37172621 DOI: 10.1016/j.jvs.2023.04.041] [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: 06/17/2022] [Revised: 03/28/2023] [Accepted: 04/09/2023] [Indexed: 05/15/2023]
Abstract
OBJECTIVE The volume-outcomes relationship is cross-cutting among open abdominal aortic operations, where higher-volume surgeons have better perioperative outcomes. However, there has been minimal focus on low-volume surgeons and how to improve their outcomes. This study sought to identify if there are any differences in outcomes among low-volume surgeons for open abdominal aortic surgeries by different hospital settings. METHODS We used the 2012-2019 Vascular Quality Initiative registry to identify all patients who underwent open abdominal aortic surgery for aneurysmal or aorto-iliac occlusive disease by a low-volume surgeon (<7 operations annually). We categorized high-volume hospitals using three distinct definitions: those that performed ≥10 operations annually, those with at least one high-volume surgeon, and by the number of surgeons (1-2 surgeons, 3-4 surgeons, 5-7 surgeons, and 8+ surgeons). Outcomes included 30-day perioperative mortality, overall complications, and failure-to-rescue. We compared outcomes among low-volume surgeons using univariable and multivariable logistic regressions across each of these three hospital categorizations. RESULTS Among 14,110 patients who underwent open abdominal aortic surgery, 10,252 (7 3%) were performed by 1155 low-volume surgeons. Two-thirds of these patients (66%) underwent their surgery at a high-volume hospital, fewer than one-third (30%) at a hospital that had at least one high-volume surgeon, and one-half (49%) at hospitals with at least five surgeons. Among all patients operated on by low-volume surgeons, rates of 30-day mortality were 3.8%, perioperative complications were 35.3%, and failure-to-rescue were 9.9%. Low-volume surgeons operating at high-volume hospitals for aneurysmal disease had lower rates of perioperative death (adjusted odds ratio [aOR], 0.66; 95% confidence interval [CI], 0.48-0.90) and failure-to-rescue (aOR, 0.70; 95% CI, 0.50-0.98), but similar rates of complications (aOR, 1.06; 95% CI, 0.89-1.27). Similarly, patients undergoing their operation at hospitals that had at least one high-volume surgeon had lower rates of death (aOR, 0.71; 95% CI, 0.50-0.99) for aneurysmal disease. Patient outcomes among low-volume surgeons for aorto-iliac occlusive disease did not vary by hospital setting. CONCLUSIONS The majority of patients undergoing open abdominal aortic surgery have a low-volume surgeon, where outcomes are slightly better for those taking place at a high-volume hospital. Focused and incentivized interventions may be needed to improve outcomes among low-volume surgeons across all practice settings.
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Affiliation(s)
- Ambar Mehta
- Division of Cardiac, Thoracic, and Vascular Surgery, New York-Presbyterian Columbia University Medical Center, New York, NY
| | - Priya Patel
- Division of Cardiac, Thoracic, and Vascular Surgery, New York-Presbyterian Columbia University Medical Center, New York, NY; Division of General Surgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Adham Elmously
- Division of Cardiac, Thoracic, and Vascular Surgery, New York-Presbyterian Columbia University Medical Center, New York, NY
| | - James Iannuzzi
- Division of Vascular and Endovascular Surgery, UCSF, San Francisco, CA
| | - Karan Garg
- Division of Vascular and Endovascular Surgery, NYU Langone Health, New York, NY
| | - Jeffrey Siracuse
- Division of Vascular and Endovascular Surgery, Boston University, Boston, MA
| | - Hiroo Takayama
- Division of Cardiac, Thoracic, and Vascular Surgery, New York-Presbyterian Columbia University Medical Center, New York, NY
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Thomas F X O'Donnell
- Division of Cardiac, Thoracic, and Vascular Surgery, New York-Presbyterian Columbia University Medical Center, New York, NY
| | - Virendra I Patel
- Division of Cardiac, Thoracic, and Vascular Surgery, New York-Presbyterian Columbia University Medical Center, New York, NY.
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Tomee SM, Bulder RMA, Meijer CA, van Berkum I, Hinnen JW, Schoones JW, Golledge J, Bastiaannet E, Matsumura JS, Hamming JF, Hultgren R, Lindeman JH. Excess Mortality for Abdominal Aortic Aneurysms and the Potential of Strict Implementation of Cardiovascular Risk Management: A Multifaceted Study Integrating Meta-Analysis, National Registry, and PHAST and TEDY Trial Data. Eur J Vasc Endovasc Surg 2023; 65:348-357. [PMID: 36460276 DOI: 10.1016/j.ejvs.2022.11.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 11/02/2022] [Accepted: 11/23/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Previous studies imply a profound residual mortality risk following successful abdominal aorta aneurysm (AAA) repair. This excess mortality is generally attributed to increased cardiovascular risk. The aim of this study was (1) to quantify the excess residual mortality for patients with AAA, (2) to evaluate the cross sectional level of cardiovascular risk management, and (3) to estimate the potential of optimised cardiovascular risk management to reduce the excess mortality in these patients. METHODS Excess mortality was estimated through a systematic review and meta-analysis, and through data from the Swedish National Health Registry. Cardiovascular risk profiles were individually assessed during eligibility screening of patients with AAA for two multicentre pharmaceutical AAA stabilisation trials. The potential of full implementation of cardiovascular risk management was estimated through the validated Second Manifestations of ARTerial disease (SMART) risk scores algorithm. RESULTS The meta-analysis showed a similarly impaired survival for patients who received early repair (small AAA) or regular repair (≥ 55 mm), and a further impaired survival for patients under surveillance for a small AAA. Excess mortality was further quantified using Swedish population data. The data revealed a more than quadrupled and doubled five year mortality rate for women and men who had their AAA repaired, respectively. Evaluation of the level of risk management of 358 patients under surveillance in 16 Dutch hospitals showed that the majority of patients with AAA did not meet therapeutic targets set for risk management in high risk populations, and indicated a more pronounced prevention gap in women. Application of the SMART risk score algorithm predicted that optimal implementation of risk management guidelines would reduce the 10 year risk of major adverse cardiovascular events from 43% to 14%. CONCLUSION Independent of the rupture risk, AAA is associated with a worryingly compromised life expectancy with a particularly poor prognosis for women. Optimal implementation of cardiovascular risk prevention guidelines is predicted to profoundly reduce cardiovascular risk.
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Affiliation(s)
- Stephanie M Tomee
- Department of Vascular Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - Ruth M A Bulder
- Department of Vascular Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - C Arnoud Meijer
- Department of Radiology, Martini Hospital, Groningen, the Netherlands
| | - Ingrid van Berkum
- Department of Vascular Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - Jan-Willem Hinnen
- Department of Vascular Surgery, Jeroen Bosch Hospital, 's-Hertogenbosch, GZ, the Netherlands
| | - Jan W Schoones
- Walaeus Library, Leiden University Medical Centre, Leiden, the Netherlands
| | - Jonathan Golledge
- The Vascular Biology Unit, Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Australia; Department of Vascular and Endovascular Surgery, The Townsville Hospital, Townsville, Australia
| | - Esther Bastiaannet
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - Jon S Matsumura
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Jaap F Hamming
- Department of Vascular Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - Rebecka Hultgren
- Department of Vascular Surgery, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Jan H Lindeman
- Department of Vascular Surgery, Leiden University Medical Centre, Leiden, the Netherlands.
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Alberga AJ, de Bruin JL, Verhagen HJ. Response to commentary on 'Treatment Outcome Trends for Non-Ruptured Abdominal Aortic Aneurysms: A Nationwide Prospective Cohort Study'. Eur J Vasc Endovasc Surg 2022; 64:137-138. [PMID: 35589089 DOI: 10.1016/j.ejvs.2022.05.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 05/09/2022] [Accepted: 05/10/2022] [Indexed: 11/26/2022]
Affiliation(s)
- Anna J Alberga
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands; Scientific Bureau, Dutch Insitute for Clinical Auditing, Leiden, the Netherlands.
| | - Jorg L de Bruin
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Hence Jm Verhagen
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands
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Rajani RR. Is maximum aortic diameter a surrogate marker of access to healthcare? J Vasc Surg 2021; 74:433. [PMID: 34303473 DOI: 10.1016/j.jvs.2021.01.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 01/26/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Ravi R Rajani
- Division of Vascular Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Ga
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