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Feridooni T, Gordon L, Mahmood DN, Behdinan A, Eisenberg N, Crawford S, Lindsay TF, Roche-Nagle G. Age is not a sole predictor of outcomes in octogenarians undergoing complex endovascular aortic repair. J Vasc Surg 2024:S0741-5214(24)00952-2. [PMID: 38604321 DOI: 10.1016/j.jvs.2024.03.451] [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: 12/27/2023] [Revised: 03/22/2024] [Accepted: 03/31/2024] [Indexed: 04/13/2024]
Abstract
OBJECTIVE To examine the perioperative, postoperative, and long-term outcomes of fenestrated/branched endovascular aneurysm repair (F/BEVAR) in octogenarians compared with nonoctogenarians. METHODS A multicenter, retrospective cohort study was conducted using the Vascular Quality Improvement database, which prospectively captures information on patients who undergo vascular surgery across 1021 academic and community hospitals in North America. All patients who underwent F/BEVAR endovascular aortic repair from 2012 to 2022 were included. Patients were stratified into two groups: those aged <80 years and those aged ≥80 years at the time of the procedure. The preoperative, intraoperative, and postoperative factors were compared between the two groups. The primary outcome was long-term all-cause mortality; secondary outcomes included aortic-specific mortality and aortic-specific reintervention. RESULTS A total of 6007 patients (aged <80 years, n = 4860; aged ≥80 years, n = 1147) who had undergone F/BEVAR procedures were included. No significant difference was found in technical success, postoperative length of stay, length of intensive care unit stay, postoperative bowel ischemia, and spinal cord ischemia. After adjustment for baseline covariates, octogenarians were more likely to suffer from a postoperative complication (odds ratio [OR]: 1.16; [95% confidence interval (CI): 0.98-1.37], P < .001) and be discharged to a rehabilitation center (OR: 1.60; [95% CI: 1.27-2.00], P < .001) or nursing home (OR: 2.23; [95% CI: 1.64-3.01], P < .001). Five-year survival was lower in octogenarians (83% vs 71%, hazard ratio [HR]: 1.70; [95% CI: 1.46-2.0], P < .0001). Multivariate Cox proportional hazard analysis demonstrated that age was associated with increased all-cause mortality (HR: 1.72, [95% CI: 1.39-2.12], P < .001) and aortic-specific mortality (HR: 1.92, [95% CI: 1.04-3.68], P = .038). Crawford extent II aortic disease was associated with an increase in all-cause mortality (HR 1.49; [95% CI: 1.01-2.19], P < .001), aortic-specific mortality (HR: 5.05; [95% CI: 1.35-18.9], P = .016), and aortic-specific reintervention (HR: 1.91; [95% CI: 1.24-2.93], P = .003). Functional dependence was associated with increased all-cause mortality (HR: 2.90; [95% CI: 1.87-4.51], P < .001) and aortic-specific mortality (HR: 4.93; [95% CI: 1.69-14.4], P = .004). CONCLUSIONS Our findings suggest that octogenarians do have a mildly increased mortality rate and rate of adverse events after F/BEVAR procedures. Despite this, when adjusted for other risk factors, on par with other medical comorbidities and therefore age should be strict exclusion criterion for F/BEVAR procedures, rather age should be considered in the global context of patient's aortic anatomy, health, and functional status.
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Affiliation(s)
- Tiam Feridooni
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Lauren Gordon
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Daniyal N Mahmood
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Asha Behdinan
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Naomi Eisenberg
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Sean Crawford
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Thomas F Lindsay
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Graham Roche-Nagle
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada.
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Elahwal M, Richards T, Imsirovic A, Bagga R, Almond G, Yusuf SW. Systematic review of the results of fenestrated endovascular aortic repair in octogenarians. Ann R Coll Surg Engl 2024; 106:106-117. [PMID: 37642117 PMCID: PMC10830342 DOI: 10.1308/rcsann.2023.0032] [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] [Accepted: 04/04/2023] [Indexed: 08/31/2023] Open
Abstract
INTRODUCTION With the increasing life expectancy of Western populations, more octogenarians are presenting with large abdominal aortic aneurysm (AAA). Endovascular repair offers a less invasive alternative and older patients who may not have been offered open repair in the past are now being considered for elective repair with this approach. Age in isolation may not be the only consideration in recommending elective aneurysm repair. We aimed to review the literature on complex endovascular AAA repairs (mainly fenestrated endovascular aortic repair [FEVAR]) in octogenarians. METHODS A literature search was conducted using the Ovid Medline®, Embase® and Cochrane Library databases for articles published up to January 2022. All English language publications from 1995 onwards were eligible for inclusion. Search terms included: "FEVAR", "F-EVAR", "fenestrated EVAR", "fenestrated endovascular aortic repair", "fenestrated endovascular aneurysm repair", "fenestrated AAA repair", "fenestrated endograft", "fenestrated stent graft", "fenestrated", "endograft", "EVAR", "octogenarian", "elderly", "above 80" and "over 80". METHODS The literature search identified 134 potential articles. Following qualitative assessment by two independent appraisers, this was refined to 11 studies, in accordance with the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) statement. RESULTS The primary outcome measure was 30-day mortality, which was highly variable, ranging from 0% to 9% in octogenarians and from 0% to 5% in non-octogenarians. However, these differences were only found to be statistically significant in two studies. The secondary outcome measures included technical success rates, major adverse events, reintervention rates, freedom from reintervention, target vessel patency, freedom from target branch instability, and length of hospital and intensive care unit stay. No statistically significant differences were found between octogenarians and non-octogenarians. Long-term survival was significantly lower for octogenarians in two studies. CONCLUSIONS The perioperative outcomes of FEVAR in octogenarians are comparable with those of younger patients. FEVAR therefore appears to be an acceptable option for complex endovascular aneurysm repairs in carefully selected octogenarians. Nevertheless, this review highlights the paucity of published data on the outcomes of endovascular repair of complex aneurysms in octogenarians.
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Affiliation(s)
- M Elahwal
- University Hospitals Sussex NHS Foundation Trust, UK
| | - T Richards
- University Hospitals Sussex NHS Foundation Trust, UK
| | - A Imsirovic
- University Hospitals Sussex NHS Foundation Trust, UK
| | - R Bagga
- University Hospitals Sussex NHS Foundation Trust, UK
| | - G Almond
- University Hospitals Sussex NHS Foundation Trust, UK
| | - SW Yusuf
- University Hospitals Sussex NHS Foundation Trust, UK
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Penton A, DeJong M, Zielke T, Nam J, Blecha M. The Impact of Perioperative Morbidities, Lack of Discharge Aspirin, and Lack of Discharge Statin on Long Term Survival Following EVAR. Vasc Endovascular Surg 2023; 57:717-725. [PMID: 37098123 DOI: 10.1177/15385744231173198] [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] [Indexed: 04/27/2023]
Abstract
OBJECTIVE Adverse perioperative events and discharge medications both have the potential to impact survival following endovascular abdominal aortic aneurysm repair (EVAR). We hypothesize that variables such as blood loss, reoperation in the same hospital admission, and lack of discharge statin/aspirin have significant effect on long term survival following EVAR. Similarly, other perioperative morbidities, are hypothesized to affect long term mortality. Quantifying the mortality effect of perioperative events and treatment emphasizes to physicians the critical nature of preoperative optimization, case planning, operative execution and postoperative patient management. METHODS All EVAR in the Vascular Quality Initiative between 2003 and 2021 were queried. Exclusions were: ruptured/symptomatic aneurysm; concomitant renal artery or supra-renal intervention at the time of EVAR; conversion to open aneurysm repair at the time of initial operation; and undocumented mortality status at the 5 year mark postoperatively. 18,710 patients met inclusion criteria. Multivariable Cox regression time dependent analysis was performed to investigate the strength of mortality association of the exposure variables. Standard demographic variables and pre-existing major co-morbidities were included in the regression analysis to account for disproportionate, deleterious co-variables amongst those experiencing the various morbidities. Kaplan-Meier survival analysis was performed to provide survival curves for the key variables. RESULTS Mean follow up was 5.99 years and 5-year survival for included patients was 69.2%. Cox regression revealed increased long term mortality to be associated with the following perioperative events: reoperation during the index hospital admission (HR 1.21, P = .034), perioperative leg ischemia (HR 1.34, P = .014), perioperative acute renal insufficiency (HR 1.24, P = .013), perioperative myocardial infarction (HR 1.87, P < .001), perioperative intestinal ischemia (HR 2.13, P < .001), perioperative respiratory failure (HR 2.15, P < .001), lack of discharge aspirin (HR 1.26, P < .001), and lack of discharge statin (HR 1.26, P < .001). The following pre-existing co-morbidities correlated with increased long term mortality (P < .001 for all) : body mass index under 20 kg/m2, hypertension, diabetes, coronary artery disease, reported history congestive heart failure, chronic obstructive pulmonary disease, peripheral artery disease, advancing age, baseline renal insufficiency and left ventricular ejection fraction less than 50%. Females were more likely to have EBL >300 mL, reoperation, perioperative MI, limb ischemia and acute renal insufficiency than males (P < .01 for all). Female sex trended but was not associated with increased long term mortality risk (HR 1.06, 95% CI .995-1.14, P = .072). CONCLUSIONS Survival after EVAR is improved with optimal operative planning to facilitate evading the need for reoperation and ensuring patients without contra-indication are discharged with aspirin and statin medications. Females and patients with pre-existing co-morbidity are at particularly higher risk for perioperative limb ischemia, renal insufficiency, intestinal ischemia and myocardial ischemia necessitating appropriate preparation and preventative measures.
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Affiliation(s)
- Ashley Penton
- Department of Surgery, Loyola University Medical Center, Maywood, IL, USA
| | - Matthew DeJong
- Department of Surgery, Loyola University Medical Center, Maywood, IL, USA
| | - Tara Zielke
- Stritch School of Medicine, Loyola University Chicago, Maywood, IL, USA
| | - Janice Nam
- Stritch School of Medicine, Loyola University Chicago, Maywood, IL, USA
| | - Matthew Blecha
- Division of Vascular Surgery and Endovascular Therapy, Loyola University Health System, Maywood, IL, USA
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Mahmood DN, Forbes SM, Rocha R, Tan K, Ouzounian M, Chung JCY, Lindsay TF. Outcomes in octogenarians after thoracoabdominal and juxtarenal aortic aneurysm repair using fenestrated-branched devices justifies treatment. J Vasc Surg 2023; 77:694-703.e3. [PMID: 36441071 DOI: 10.1016/j.jvs.2022.10.028] [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: 07/07/2022] [Revised: 10/13/2022] [Accepted: 10/17/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To compare outcomes between octogenarians and nonoctogenarians undergoing thoracoabdominal aortic aneurysm repair and juxtarenal aortic aneurysm repair using branched and/or fenestrated endovascular devices (F/BEVAR) and compare octogenarian survival to population survival statistics from Ontario, Canada. METHODS Patients who underwent F/BEVAR at a single institution between 2007 and 2020 were retrospectively reviewed with a median follow-up of 3.3 years (interquartile range, 1.6-5.3). The median survival of an average 84-year-old Ontarian from Canada, adjusted for a male:female ratio of 4:1, was retrieved from publicly available Statistics Canada data. RESULTS In total, 68 octogenarians (25.8%) and 196 nonoctogenarians (74.2%) were included (mean age, 83.5 ± 3.0 vs 71.9 ± 5.8 years; P ≤ .001). The maximum aneurysm size was significantly larger in octogenarians (68.9 ± 11.4 mm vs 65.4 ± 10.0 mm; P = .017). No differences in the number of thoracoabdominal aortic aneurysm repairs (29.4% vs 38.3%; P = .19) or operative technical success (92.6% vs 85.7%; P = .136) were observed between the two cohorts. Postoperatively, no significant differences in overall in-hospital mortality (7.3% vs 5.1%; P = .49), elective in-hospital mortality (6.1% vs 4.4%; P = .49), stroke (1.5% vs 3.6%; P = .384), or spinal cord ischemia (2.9% vs 9.2%; P = .094) were seen between octogenarians and nonoctogenarians. There was no difference in survival at 4 years between the two cohorts (62.9% vs 71.1%; P = .22), however, survival at 6 years was significantly lower for octogenarians (44.5% vs 64.1%; hazard ratio, 1.96; P = .02). The cumulative rate of reintervention (44.1% vs 41.3%; P = .84) and freedom from branch instability (67.6% vs 73.5%; P = .33) at 6 years were not different between the two groups. When comparing octogenarians who survived to discharge from index hospitalization after F/BEVAR with 84-year-old Ontarians unmatched for comorbidities, a survival difference of 4.8% and 11.1% was noted at 4 and 6 years, respectively. CONCLUSIONS F/BEVAR in octogenarians is associated with no differences in technical success or postoperative adverse outcomes when compared with their younger counterparts. Octogenarians had increased mortality after 4 years and their survival at 4 years was comparable with that of an 84-year-old Ontarian. F/BEVAR was safe and effective in octogenarians deemed fit for intervention. Further research into preoperative patient selection and improving perioperative outcomes is needed.
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Affiliation(s)
- Daniyal N Mahmood
- Division of Vascular Surgery, Peter Munk Cardiac Centre, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Samantha M Forbes
- Division of Vascular Surgery, Peter Munk Cardiac Centre, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Rodolfo Rocha
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - KongTeng Tan
- Division of Interventional Radiology, Toronto General Hospital, Toronto, Ontario, Canada
| | - Maral Ouzounian
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Jennifer C-Y Chung
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Thomas F Lindsay
- Division of Vascular Surgery, Peter Munk Cardiac Centre, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
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Wang G, Sun Y, Lin Z, Fei X. Elective Endovascular vs Open Repair for Elective Abdominal Aortic Aneurysm in Patients ≥80 years of Age: A Systematic Review and Meta-Analysis. Vasc Endovascular Surg 2023; 57:386-401. [PMID: 36597592 DOI: 10.1177/15385744221149911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE To provide updated, pooled evidence on clinical outcomes among octogenarians (aged ≥80 years) with abdominal aortic aneurysm (AAA) managed by elective endovascular repair, compared to conventional open repair. METHODS PubMed, Embase, and Scopus databases were systematically searched. Studies that were either observational or randomized controlled trials were considered for the review. Included studies were conducted in elderly subjects (≥80 years) with AAA, and clinical and mortality outcomes were compared between endovascular and open surgical repair. Those reporting on outcomes of patients with urgent repair were excluded. The primary outcomes of interest were mortality and risk of complications. The pooled effect sizes were reported as odds ratio (OR) for categorical outcomes and weighted mean difference (WMD) for continuous outcomes. STATA software was used for statistical analysis. RESULTS The meta-analysis included 15 studies. Compared to those undergoing open repair, patients receiving endovascular repair had significantly reduced risk of immediate post-operative mortality (OR .23, 95% CI: .20, .27), overall complication (OR .30, 95% CI: .20, .44), cardiac (OR .23, 95% CI: .16, .35), renal (OR .29, 95% CI: .18, .46), pulmonary (OR .14, 95% CI: .09, .21) and bleeding related (OR .59, 95% CI: .42, .83) complications. The risk of mortality at latest follow up (at 36 months and 60 months) was similar in the two groups. The total blood loss (ml) (WMD -1126.47, 95% CI: -1497.81, -755.13), operative time (min) (WMD -29.40, 95% CI: -56.19, -2.62), length of intensive care unit stay (days) (WMD -2.27, 95% CI: -3.43, -2.12) and overall hospital stay (days) (WMD -6.64, 95% CI: -7.60, -5.68) was significantly lower in those undergoing endovascular repair. CONCLUSIONS Endovascular repair appears to be better than open repair of AAA in this high-risk, frail population, with respect to short term outcomes. The benefits of reduced risk of short term mortality, complications, and better peri and post-operative outcomes may be considered when making a choice between these two surgical approaches. Randomized controlled trials are needed to provide reliable evidence on the effect of EVAR on long term survival.
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Affiliation(s)
- Guohua Wang
- Department of Vascular Hernia Surgery, 74682Shaoxing People's Hospital, Shaoxing, China
| | - Yifeng Sun
- Department of Vascular Hernia Surgery, 74682Shaoxing People's Hospital, Shaoxing, China
| | - Zhiqiang Lin
- Department of Vascular Hernia Surgery, 74682Shaoxing People's Hospital, Shaoxing, China
| | - Xiaozhou Fei
- Department of Vascular Hernia Surgery, 74682Shaoxing People's Hospital, Shaoxing, China
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Park JK, Kang J, Kim YW, Kim DI, Heo SH, Gil E, Woo SY, Park YJ. Outcomes after Elective Open Abdominal Aortic Aneurysm Repair in Octogenarians Compared to Younger Patients in Korea. J Korean Med Sci 2021; 36:e314. [PMID: 34873883 PMCID: PMC8648610 DOI: 10.3346/jkms.2021.36.e314] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 10/15/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Although the first choice of treatment for abdominal aortic aneurysm (AAA) is endovascular aneurysm repair, especially in elderly patients, some patients require open surgical repair. The purpose of this study was to compare the mortality outcomes of open AAA repair between octogenarians and younger counterparts and to identify the risk factors associated with mortality. METHODS All consecutive patients who underwent elective open AAA repair due to degenerative etiology at a single tertiary medical center between 1996 and June 2020 were included in this retrospective review. Medical records and imaging studies were reviewed to collect the following information: demographics, comorbid medical conditions, clinical presentations, radiologic findings, surgical details, and morbidity and mortality rates. For analysis, patients were divided into two groups: older and younger than 80 years of age. Multivariate analysis was performed to identify factors associated with mortality after elective open AAA repair. RESULTS Among a total of 650 patients who underwent elective open AAA repair due to degenerative AAA during the study period, 58 (8.9%) were octogenarians and 595 (91.1%) were non-octogenarians. Patients in the octogenarian group were predominantly female and more likely to have lower body weight and body mass index (BMI), hypertension, chronic kidney disease, and lower preoperative serum hemoglobin and albumin compared with patients in the non-octogenarian group. Maximal aneurysm diameter was larger in octogenarians. During the median follow-up duration of 34.4 months for 650 patients, the median length of total hospital and intensive care unit stay was longer in octogenarians. The 30-day (1.7% vs. 0.7%, P = 0.374) and 1-year (6.9% vs. 2.9%, P = 0.108) mortality rates were not statistically significantly different between the two groups. Multivariate analysis showed that low BMI was associated with increased 30-day (odds ratio [OR], 16.339; 95% confidence interval [CI], 1.192-224.052; P = 0.037) and 1-year (OR, 8.236; CI, 2.301-29.477; P = 0.001) mortality in all patients. CONCLUSION Because the mortality rate of octogenarians after elective open AAA repair was not significantly different compared with their younger counterparts, being elderly is not a contraindication for open AAA repair. Low BMI might be associated with increased postoperative mortality.
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Affiliation(s)
- Joon-Kee Park
- Division of Vascular Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jihee Kang
- Division of Vascular Surgery, Department of Surgery, Inha University Hospital, Inha University School of Medicine, Incheon, Korea
| | - Young-Wook Kim
- Division of Vascular Surgery, Department of Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dong-Ik Kim
- Division of Vascular Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seon-Hee Heo
- Department of Surgery, Yonsei University School of Medicine, Seoul, Korea
| | - Eunmi Gil
- Department of Critical Care Medicine and Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Shin-Young Woo
- Division of Vascular Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yang-Jin Park
- Division of Vascular Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
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The Impact of the Aging Population on Surgical Diseases. CURRENT GERIATRICS REPORTS 2021. [DOI: 10.1007/s13670-020-00352-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Motta F, Oderich GS, Tenorio ER, Schanzer A, Timaran CH, Schneider D, Sweet MP, Beck AW, Eagleton MJ, Farber MA. Fenestrated-branched endovascular aortic repair is a safe and effective option for octogenarians in treating complex aortic aneurysm compared with nonoctogenarians. J Vasc Surg 2021; 74:353-362.e1. [PMID: 33548425 DOI: 10.1016/j.jvs.2020.12.096] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 12/31/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Open repair of complex aortic aneurysms is frequently not an option for octogenarians because of prohibitive surgical risks. This study aimed to analyze the outcomes of fenestrated-branched endovascular aortic repair (F-BEVAR) in octogenarians (≥80 years old) compared with nonoctogenarians (<80 years old). METHODS We reviewed 893 patients with pararenal or extent I to V thoracoabdominal aneurysms, enrolled in six prospective physician-sponsored investigational device exemption studies from 2012 to 2018. All patients were treated with either company-manufactured off-the-shelf or patient-specific F-BEVAR stent grafts. Data analyzed included demographics, cardiovascular risk factors, history of active cancer, American Society of Anesthesiologists classification, aortic anatomy characteristics, and procedural data. End points included mortality, major adverse events (all-cause mortality, stroke, paralysis, acute kidney injury [RIFLE criteria], dialysis, myocardial infarction, respiratory failure, and bowel ischemia), technical success, hospital length of stay, target artery instability (occlusion/stenosis, endoleak, rupture or death), and secondary interventions. RESULTS During the study period, 195 octogenarian patients (22%) and 698 (78%) nonoctogenarian patients were treated with F-BEVAR. Octogenarians presented more frequently with a history of cancer (17% vs 11%; P = .01), whereas nonoctogenarians more frequently had hyperlipidemia (76% vs 65%; P = .003), chronic obstructive pulmonary disease (42% vs 33%; P = .04) and American Society of Anesthesiologists class III to V (78% vs 70%; P = .02). Male sex was similar between groups (68% [octogenarians] vs 70% [nonoctogenarians]; P = .62). Octogenarians had a larger mean aneurysm diameter (67 ± 1 mm vs 65 ± 1 mm; P = .002). The thoracoabdominal classification and the use of upper extremity access were similar between groups. Estimated blood loss was also similar (484 ± 454 mL [octogenarian] vs 416 ± 457 mL [nonoctogenarian]; P = .07). Octogenarians had an increased mean number of vessels incorporated into the repair (3.1 ± 1.4 vs 2.7 ± 1.7; P < .001). The technical success rate was 99% for octogenarians and 97% for nonoctogenarians (P = .19). The 30-day mortality rate was 0.5% for octogenarians and 1.3% for the nonoctogenarians (P = .70). Major adverse events (9.2% vs 9.7%), types I/III endoleak (4.6% vs 2.4%) access complication (3.1% vs 3.3%), and length of stay (8.2 ± 27 days vs 5.7 ± 6.3 days) were all similar between the groups. Freedom from target artery instability and freedom from secondary interventions at 3 years were similar between the groups. Octogenarian survival was lower at 3 years compared with nonoctogenarians on univariate analysis (log-rank P < .01) and on multivariable analysis after adjusting for history of active cancer, hyperlipidemia, and chronic obstructive pulmonary disease. CONCLUSIONS Despite small differences in demographics, anatomic factors, and procedural data, F-BEVAR was safe and effective with nearly identical early outcomes in octogenarians in these experienced aortic centers. More extensive clinical experience and longer follow-up are needed to better delineate factors impacting longer term mortality.
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Affiliation(s)
- Fernando Motta
- Division of Vascular and Endovascular Surgery, The University of North Carolina, Chapel Hill, NC
| | - Gustavo S Oderich
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Emanuel R Tenorio
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Andres Schanzer
- Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester, Mass
| | - Carlos H Timaran
- Division of Vascular and Endovascular Surgery, University of Texas Southwestern, Dallas, Tex
| | - Darren Schneider
- Weill Cornell Medicine, New York-Presbyterian Hospital, New York, NY
| | - Matthew P Sweet
- Division of Vascular and Endovascular Surgery, University of Washington, Seattle, Wash
| | - Adam W Beck
- Division of Vascular and Endovascular Surgery, University of Alabama at Birmingham, Birmingham, Ala
| | - Matthew J Eagleton
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Mark A Farber
- Division of Vascular and Endovascular Surgery, The University of North Carolina, Chapel Hill, NC.
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Kim TI, Brahmandam A, Skrip L, Sarac T, Dardik A, Ochoa Chaar CI. Surgery for the Very Old: Are Nonagenarians Different? Am Surg 2020. [DOI: 10.1177/000313482008600129] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Octogenarians and nonagenarians are considered the “very old” and are often viewed as one group. Americans are aging, with the proportion of the very old expected to increase from 1.9 per cent of the population to 4.3 per cent in 2050. This study aimed to underscore the differences in surgical trends, demographics, and outcomes between octogenarians and nonagenarians. The ACS-NSQIP database (2007–2012) was used to derive the type of surgeries, demographics, and outcomes of octogenarian and nonagenarians undergoing nonemergent vascular, orthopedic, and general surgery procedures. Between 2007 and 2012, nonagenarians accounted for an increasing percentage of surgeries (85 to 121 per 10,000 surgeries, relative risk = 1.42; 95% CI: 1.30–1.54) across surgical specialties, including vascular, general, and orthopedic surgery, whereas the percentage of octogenarians undergoing surgery remained unchanged. Nonagenarians had a higher 30-day perioperative mortality and a longer hospital stay than octogenarians after vascular, orthopedic, and general surgery procedures. Nonagenarians are a rapidly growing group of surgical patients with significantly higher perioperative mortality and longer postoperative hospital stay. The impact of surgery on the quality of life of nonagenarians needs to be studied to justify the increasing healthcare costs.
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Affiliation(s)
- Tanner I. Kim
- Division of Vascular Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Anand Brahmandam
- Division of Vascular Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Laura Skrip
- Yale School of Public Health, New Haven, Connecticut; and
| | - Timur Sarac
- Division of Vascular Diseases and Surgery, Department of Surgery, Ohio State University School of Medicine, Columbus, Ohio
| | - Alan Dardik
- Division of Vascular Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Cassius Iyad Ochoa Chaar
- Division of Vascular Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
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10
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Mwipatayi BP, Oshin OA, Faraj J, Varcoe RL, Wong J, Becquemin JP, Riambau V, Böckler D, Verhagen HJ. Analysis of Midterm Outcomes of Endovascular Aneurysm Repair in Octogenarians From the ENGAGE Registry. J Endovasc Ther 2020; 27:836-844. [PMID: 32436808 DOI: 10.1177/1526602820923827] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE To assess periprocedural results and secondary endovascular procedure outcomes over 5 years in patients aged ≥80 vs <80 years undergoing endovascular aneurysm repair (EVAR). MATERIALS AND METHODS Data from the Endurant Stent Graft Natural Selection Global post-market registry (ENGAGE) were used for the analyses. A total of 1263 consecutive patients were enrolled in the prospective, observational, single-arm registry and divided into 2 groups according to age: ≥80 years (290, 22.9%) and <80 years (973, 77.1%). Baseline patient characteristics, risk scores according to the Society for Vascular Surgery (SVS) reporting standards, American Society of Anesthesiologists (ASA) classification, quality of life assessments [EuroQol 5 (EQ5D) index], and treatment outcomes, including all-cause mortality, aneurysm-related mortality, major adverse events, secondary endovascular procedures, and endoleaks were compared between groups. RESULTS Octogenarians were classified into the highest category of the SVS risk stratification system; however, this did not result in a significant difference in the 30-day mortality [1.4% (4/290) vs 1.2% (12/973) for controls; p=0.85] or major adverse event rates [5.2% (15/290) vs 3.6% (35/973), p=0.23]. Multivariable analysis confirmed that age ≥80 years, pulmonary disease, large aneurysm diameter, and renal insufficiency were significantly associated with all-cause mortality, whereas diameter was the only parameter associated with increased aneurysm-related mortality. The differences in freedom from secondary endovascular procedures over 5 years between octogenarians and controls did not reach statistical significance (88.5% vs 83.2%, p=0.07). CONCLUSION EVAR can be performed in individuals aged ≥80 years with no statistically significant difference in midterm aneurysm-related deaths compared with younger patients. The findings in this elderly patient cohort show that EVAR can be safely performed with acceptable morbidity rates in octogenarians.
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Affiliation(s)
- Bibombe P Mwipatayi
- Department of Vascular Surgery, Royal Perth Hospital, Perth, Western Australia, Australia.,School of Surgery, Faculty of Medicine, Dentistry and Health Sciences, University of Western Australia, Perth, Western Australia, Australia
| | - Olufemi A Oshin
- Department of Vascular Surgery, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Joseph Faraj
- Department of Vascular Surgery, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Ramon L Varcoe
- Department of Surgery, Prince of Wales Hospital and the University of New South Wales, Sydney, Australia
| | - Jackie Wong
- Department of Vascular Surgery, Royal Perth Hospital, Perth, Western Australia, Australia
| | | | - Vincente Riambau
- Division of Vascular Surgery, Thorax Institute, Hospital Clinic, University of Barcelona, Spain
| | - Dittmar Böckler
- Division of Vascular Surgery, University Hospital Heidelberg, Germany
| | - Hence J Verhagen
- Division of Vascular and Endovascular Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
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11
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Rueda-Ochoa OL, van Bakel P, Hoeks SE, Verhagen H, Deckers J, Rizopoulos D, Ikram MA, Rouwet E, Ultee K, Ten Raa S, Franco OH, Kavousi M, Josee van Rijn M. Survival After Uncomplicated EVAR in Octogenarians is Similar to the General Population of Octogenarians Without an Abdominal Aortic Aneurysm. Eur J Vasc Endovasc Surg 2020; 59:740-747. [PMID: 32115359 DOI: 10.1016/j.ejvs.2020.01.026] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 01/04/2020] [Accepted: 01/23/2020] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Long term survival after endovascular aortic aneurysm repair (EVAR) in octogenarians remains unclear. This was evaluated by comparing octogenarians after EVAR with a matched group of octogenarians without an abdominal aortic aneurysm (AAA) from the Rotterdam Study (RS). The influence of complications after EVAR on survival was also studied with the aim of identifying risk factors for the development of complications in octogenarians. METHODS Using propensity score matching (PSM), 83 EVAR octogenarians were matched for comorbidities with 83 octogenarians from the RS, and survival was compared between these two groups using Cox proportional hazard analysis. Then, complications were studied, defined as cardiac or pulmonary, renal deterioration, access site bleeding, acute limb ischaemia or bowel ischaemia, within 30 days of surgery between 83 EVAR octogenarians and 475 EVAR non-octogenarians. Also, the difference in baseline characteristics between the octogenarians with and without complications after EVAR were studied, and survival was compared between the RS controls and the complicated and uncomplicated EVAR octogenarians separately. RESULTS The total EVAR octogenarian population did not show an increased mortality risk compared with RS octogenarian controls (hazard ratio [HR] 1.28, 95% confidence interval [CI] 0.84-1.97). Post-operative complications occurred in 22 octogenarians (27%) and 59 non-octogenarians (12.4%, p < .001), mainly cardiac, pulmonary, and bleeding complications. All baseline characteristics were similar in the complicated EVAR octogenarians compared with the uncomplicated EVAR octogenarians. After uncomplicated EVAR, octogenarians had a similar survival compared with the RS controls (HR 1.09, 95% CI 0.68-1.77), but after complicated EVAR their mortality risk increased significantly (HR 1.93, 95% CI 1.06-3.54). CONCLUSION After standard EVAR, the life expectancy of octogenarians is the same as that of a matched group from the general population without an AAA, provided they do not develop early post-operative complications. Patient selection and meticulous peri-operative care are key.
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Affiliation(s)
- Oscar L Rueda-Ochoa
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, the Netherlands; School of Medicine, Faculty of Health, Universidad Industrial de Santander UIS, Bucaramanga, Colombia.
| | - Pieter van Bakel
- Department of Vascular Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Sanne E Hoeks
- Department of Vascular Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Hence Verhagen
- Department of Vascular Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Jaap Deckers
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Dimitris Rizopoulos
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Mohammad A Ikram
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Ellen Rouwet
- Department of Vascular Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Klaas Ultee
- Department of Vascular Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Sander Ten Raa
- Department of Vascular Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Oscar H Franco
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, the Netherlands; Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
| | - Maryam Kavousi
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, the Netherlands.
| | - Marie Josee van Rijn
- Department of Vascular Surgery, Erasmus Medical Center, Rotterdam, the Netherlands.
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12
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Henstra L, Yazar O, de Niet A, Tielliu IF, Schurink GW, Zeebregts CJ. Outcome of Fenestrated Endovascular Aneurysm Repair in Octogenarians: A Retrospective Multicentre Analysis. Eur J Vasc Endovasc Surg 2020; 59:24-30. [DOI: 10.1016/j.ejvs.2019.06.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2018] [Revised: 05/04/2019] [Accepted: 06/04/2019] [Indexed: 10/25/2022]
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13
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Lorenzi E, Henao R, Heller K. Hierarchical infinite factor models for improving the prediction of surgical complications for geriatric patients. Ann Appl Stat 2019. [DOI: 10.1214/19-aoas1292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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14
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Hsieh WC, Kan CD, Hsieh CC, Omara M, Henry BM, Davidovic LB. Improved outcomes from endovascular aortic repair in younger patients: Towards improved risk stratification. Vascular 2019; 27:573-581. [PMID: 31081493 PMCID: PMC6909194 DOI: 10.1177/1708538119843420] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Objectives Abdominal aortic aneurysms are conventionally treated by open repair surgery. While endovascular aortic repair improves survival in high-risk patients, younger patients (40–65 years) potentially at lower risk with asymptomatic abdominal aortic aneurysms undergoing endovascular aortic repair usually have poorer post-operative outcomes and require longer term follow-up. In this study, clinical data on younger patients were analyzed to investigate whether endovascular aortic repair leads to poorer short- and long-term outcomes. Methods This was a systematic review and meta-analysis of articles comparing clinical outcomes in patients aged 40–65 years undergoing open repair or endovascular aortic repair and published between 2000 and 2017. In-hospital mortality, long-term mortality, and post-operative complication data were retrieved from eligible studies and clinical outcomes were compared. Twenty-one retrospective cohort analyses were included, accounting for 250,837 patients (149,051 endovascular aortic repair; 101,786 open repair). Risk ratios were pooled using the DerSimonian and Laird random effects model. All statistical analyses were performed in Review Manager 5.3. Results Younger patients with asymptomatic abdominal aortic aneurysms undergoing endovascular aortic repair had a significantly reduced 30-day mortality (odds ratio (OR) = 0.40, 95% confidence intervals (CI) 0.28–0.57; p < 0.00001), long-term mortality (OR = 0.37, 95% CI 0.17–0.82; p = 0.01), incidence of reintervention (OR = 0.47, 95% CI 0.34–0.66; p < 0.0001), and incidence of renal failure (OR = 1.58, 95% CI 1.37–1.82; p < 0.00001). Conclusions Endovascular aortic repair may improve short- and long-term survival and reduce post-operative complications in younger patients with asymptomatic abdominal aortic aneurysms.
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Affiliation(s)
- Wan Chin Hsieh
- First Faculty of Medicine, Charles University, Prague, Czech Republic
- 2nd Department of Cardiovascular Surgery, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Chung Dann Kan
- Division of Cardiovascular Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chong Chao Hsieh
- Division of Cardiovascular Surgery, Kaohsiung Medical University School of Medicine, Chung-Ho Memorial Hospital, Kaohsiung, Taiwan, ROC
| | - Mohamed Omara
- Department of Thoracic and Cardiovascular Surgery, Research Institute, Cleveland Clinic, Cleveland, USA
| | - Brandon Michael Henry
- Division of Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Lazar B Davidovic
- Center for Vascular and Endovascular Surgery, Clinical Center of Serbia, Belgrade, Serbia
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15
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McDonald SR, Heflin MT, Whitson HE, Dalton TO, Lidsky ME, Liu P, Poer CM, Sloane R, Thacker JK, White HK, Yanamadala M, Lagoo-Deenadayalan SA. Association of Integrated Care Coordination With Postsurgical Outcomes in High-Risk Older Adults: The Perioperative Optimization of Senior Health (POSH) Initiative. JAMA Surg 2019; 153:454-462. [PMID: 29299599 DOI: 10.1001/jamasurg.2017.5513] [Citation(s) in RCA: 111] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Importance Older adults undergoing elective surgery experience higher rates of preventable postoperative complications than younger patients. Objective To assess clinical outcomes for older adults undergoing elective abdominal surgery via a collaborative intervention by surgery, geriatrics, and anesthesia focused on perioperative health optimization. Design, Setting, and Participants Perioperative Optimization of Senior Health (POSH) is a quality improvement initiative with prospective data collection. Participants in an existing geriatrics-based clinic within a single-site academic health center were included if they were at high risk for complications (ie, older than 85 years or older than 65 years with cognitive impairment, recent weight loss, multimorbidity, or polypharmacy) undergoing elective abdominal surgery. Outcomes were compared with a control group of patients older than 65 years who underwent similar surgeries by the same group of general surgeons immediately before implementation of POSH. Main Outcomes and Measures Primary outcomes included length of stay, 7- and 30-day readmissions, and level of care at discharge. Secondary outcomes were delirium and other major postoperative complications. Outcomes data were derived from institutional databases linked with electronic health records and billing data sets. Results One hundred eighty-three POSH patients were compared with 143 patients in the control group. On average, patients in the POSH group were older compared with those in the control group (75.6 vs 71.9 years; P < .001; 95% CI, 2.27 to 5.19) and had more chronic conditions (10.6 vs 8.5; P = .001; 95% CI, 0.86 to 3.35). Median length of stay was shorter among POSH patients (4 days vs 6 days; P < .001; 95% CI, -1.06 to -4.21). Patients in the POSH group had lower readmission rates at 7 days (5 of 180 [2.8%] vs 14 of 142 [9.9%]; P = .007; 95% CI, 0.09 to 0.74) and 30 days (14 of 180 [7.8%] vs 26 of 142 [18.3%]; P = .004; 95% CI, 0.19 to 0.75) and were more likely to be discharged home with self-care (114 of 183 [62.3%] vs 73 of 143 [51.1%]; P = .04; 95% CI, 1.02 to 2.47). Patients in the POSH group experienced fewer mean number of complications (0.9 vs 1.4; P < .001; 95% CI, -0.13 to -0.89) despite higher rates of documented delirium (52 of 183 [28.4%] vs 8 of 143 [5.6%]; P < .001; 95% CI, 3.06 to 14.65). A greater proportion of POSH patients underwent laparoscopic procedures (92 of 183 [50%] vs 55 of 143 [38.5%]; P = .001; 95% CI, 1.04 to 2.52). Tests for interactions between POSH patients and procedure type were insignificant for all outcomes. Conclusions and Relevance Despite higher mean age and morbidity burden, older adults who participated in an interdisciplinary perioperative care intervention had fewer complications, shorter hospitalizations, more frequent discharge to home, and fewer readmissions than a comparison group.
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Affiliation(s)
- Shelley R McDonald
- Department of Medicine, Duke University Medical Center, Durham, North Carolina.,Geriatric Research, Education, and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina.,Center for the Study of Aging, Duke University Medical Center, Durham, North Carolina
| | - Mitchell T Heflin
- Department of Medicine, Duke University Medical Center, Durham, North Carolina.,Geriatric Research, Education, and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina.,Center for the Study of Aging, Duke University Medical Center, Durham, North Carolina
| | - Heather E Whitson
- Department of Medicine, Duke University Medical Center, Durham, North Carolina.,Geriatric Research, Education, and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina.,Center for the Study of Aging, Duke University Medical Center, Durham, North Carolina
| | - Thomas O Dalton
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Michael E Lidsky
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Phillip Liu
- Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Cornelia M Poer
- Center for the Study of Aging, Duke University Medical Center, Durham, North Carolina
| | - Richard Sloane
- Center for the Study of Aging, Duke University Medical Center, Durham, North Carolina
| | - Julie K Thacker
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Heidi K White
- Department of Medicine, Duke University Medical Center, Durham, North Carolina.,Center for the Study of Aging, Duke University Medical Center, Durham, North Carolina
| | - Mamata Yanamadala
- Department of Medicine, Duke University Medical Center, Durham, North Carolina.,Geriatric Research, Education, and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina.,Center for the Study of Aging, Duke University Medical Center, Durham, North Carolina
| | - Sandhya A Lagoo-Deenadayalan
- Geriatric Research, Education, and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina.,Center for the Study of Aging, Duke University Medical Center, Durham, North Carolina.,Department of Surgery, Duke University Medical Center, Durham, North Carolina
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16
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Posso M, Quintana MJ, Bellmunt S, Martínez García L, Escudero JR, Viteri-García A, Valli C, Bonfill X. GRADE-Based Recommendations for Surgical Repair of Nonruptured Abdominal Aortic Aneurysm. Angiology 2019; 70:701-710. [PMID: 30961349 DOI: 10.1177/0003319719838892] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The objective of this study was to provide evidence-based recommendations for endovascular aneurysm repair (EVAR) versus open surgical repair (OSR) for patients with a nonruptured abdominal aortic aneurysm (AAA). We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement and adhered to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. Both low- and high surgical risk patients treated with EVAR showed decreased 30-day mortality, but the low-risk group had no differences in 4-year mortality. Compared with friendly anatomy, patients with hostile anatomy had an increased risk of type I endoleak. Young patients may prefer OSR. Endovascular aneurysm repair was not cost-effective in Europe. Four conditional recommendations were formulated: (1) OSR for low-risk patients up to 80 years old, (2) EVAR for low-risk patients older than 80 years, (3) EVAR for high-risk patients as long as is anatomically feasible, and (4) OSR in patients in whom it is not anatomically feasible to perform EVAR. Based on GRADE criteria, either OSR or EVAR can be suggested to patients with nonruptured AAA taking into account their surgical risk, hostile anatomy, and age. Given the weakness of the recommendations, personal preferences are determinant.
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Affiliation(s)
- Margarita Posso
- 1 Department of Clinical Epidemiology and Public Health, University Hospital de la Santa Creu i Sant Pau IIB Sant Pau, Barcelona, Spain.,2 Iberoamerican Cochrane Centre, IIB Sant Pau, Barcelona, Spain
| | - M Jesús Quintana
- 1 Department of Clinical Epidemiology and Public Health, University Hospital de la Santa Creu i Sant Pau IIB Sant Pau, Barcelona, Spain.,3 CIBER of Epidemiology and Public Health (CIBERESP), Madrid, Spain
| | - Sergi Bellmunt
- 4 Department of Angiology, Vascular and Endovascular Surgery, Vall d'Hebron University Hospital, Barcelona, Spain.,5 Vall d'Hebron Research Institute (VHIR), Barcelona, Spain
| | | | - José R Escudero
- 6 Joint Service of Angiology, Vascular and Endovascular Surgery, Sant Pau-Dos de Mayo Hospital, Barcelona, Spain.,7 Autonomous University of Barcelona, Barcelona, Spain.,8 CIBER of Cardiovascular Diseases (CIBERCV), Madrid, Spain
| | - Andrés Viteri-García
- 9 Faculty of Health Sciences "Eugenio Espejo," Clinical Epidemiology and Public Health Research Centre (CISPEC), Universidad UTE, Quito, Ecuador
| | - Claudia Valli
- 2 Iberoamerican Cochrane Centre, IIB Sant Pau, Barcelona, Spain
| | - Xavier Bonfill
- 1 Department of Clinical Epidemiology and Public Health, University Hospital de la Santa Creu i Sant Pau IIB Sant Pau, Barcelona, Spain.,2 Iberoamerican Cochrane Centre, IIB Sant Pau, Barcelona, Spain.,3 CIBER of Epidemiology and Public Health (CIBERESP), Madrid, Spain.,7 Autonomous University of Barcelona, Barcelona, Spain
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17
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Bulder RMA, Bastiaannet E, Hamming JF, Lindeman JHN. Meta-analysis of long-term survival after elective endovascular or open repair of abdominal aortic aneurysm. Br J Surg 2019; 106:523-533. [PMID: 30883709 DOI: 10.1002/bjs.11123] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Revised: 12/06/2018] [Accepted: 12/16/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Endovascular aneurysm repair (EVAR) has become the preferred strategy for elective repair of abdominal aortic aneurysm (AAA) for many patients. However, the superiority of the endovascular procedure has recently been challenged by reports of impaired long-term survival in patients who underwent EVAR. A systematic review of long-term survival following AAA repair was therefore undertaken. METHODS A systematic review was performed according to PRISMA guidelines. Articles reporting short- and/or long-term mortality of EVAR and open surgical repair (OSR) of AAA were identified. Pooled overall survival estimates (hazard ratios (HRs) with corresponding 95 per cent c.i. for EVAR versus OSR) were calculated using a random-effects model. Possible confounding owing to age differences between patients receiving EVAR or OSR was addressed by estimating relative survival. RESULTS Some 53 studies were identified. The 30-day mortality rate was lower for EVAR compared with OSR: 1·16 (95 per cent c.i. 0·92 to 1·39) versus 3·27 (2·71 to 3·83) per cent. Long-term survival rates were similar for EVAR versus OSR (HRs 1·01, 1·00 and 0·98 for 3, 5 and 10 years respectively; P = 0·721, P = 0·912 and P = 0·777). Correction of age inequality by means of relative survival analysis showed equal long-term survival: 0·94, 0·91 and 0·76 at 3, 5 and 10 years for EVAR, and 0·96, 0·91 and 0·76 respectively for OSR. CONCLUSION Long-term overall survival rates were similar for EVAR and OSR. Available data do not allow extension beyond the 10-year survival window or analysis of specific subgroups.
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Affiliation(s)
- R M A Bulder
- Department of Vascular Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - E Bastiaannet
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - J F Hamming
- Department of Vascular Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - J H N Lindeman
- Department of Vascular Surgery, Leiden University Medical Centre, Leiden, the Netherlands
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18
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Law Y, Chan Y, Cheng S. Predictors of early operative mortality and long-term survival in octogenarians undergoing open and endovascular repair of abdominal aortic aneurysm. Asian J Surg 2018; 41:490-497. [DOI: 10.1016/j.asjsur.2017.09.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Revised: 07/17/2017] [Accepted: 09/07/2017] [Indexed: 11/15/2022] Open
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19
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Hye RJ, Janarious AU, Chan PH, Cafri G, Chang RW, Rehring TF, Nelken NA, Hill BB. Survival and Reintervention Risk by Patient Age and Preoperative Abdominal Aortic Aneurysm Diameter after Endovascular Aneurysm Repair. Ann Vasc Surg 2018; 54:215-225. [PMID: 30081171 DOI: 10.1016/j.avsg.2018.05.053] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 05/01/2018] [Accepted: 05/10/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Endovascular aneurysm repair (EVAR) has become the standard of care for abdominal aortic aneurysm (AAA), but questions remain regarding the benefit in high-risk and elderly patients. The purpose of this study was to examine the effect of age, preoperative AAA diameter, and their interaction on survival and reintervention rates after EVAR. METHODS Our integrated health system's AAA endograft registry was used to identify patients who underwent elective EVAR between 2010 and 2014. Of interest was the effect of patient age at the time of surgery (≤80 vs. >80 years old), preoperative AAA diameter (≤5.5 cm vs. >5.5 cm), and their interaction. Primary endpoints were all-cause mortality and reintervention. Between-within mixed-effects Cox models with propensity score weights were fit. RESULTS Of 1,967 patients undergoing EVAR, unadjusted rates for survival at 4 years after EVAR was 76.1%, and reintervention-free rate was 86.0%. For mortality, there was insufficient evidence for an interaction between age and AAA size (P = 0.309). Patient age >80 years was associated with 2.53-fold higher mortality risk (hazard ratios [HR] = 2.53; 95% confidence intervals [CI], 1.73-3.70; P < 0.001), whereas AAA > 5.5 cm was associated with 1.75-fold higher mortality risk (HR = 1.75; 95% CI, 1.26-2.45; P = 0.001). For reintervention risk, there were no significant interactions or main effects for age or AAA diameter. CONCLUSIONS Age and AAA diameter are independent predictors of reduced survival after EVAR, but the effect is not amplified when both are present. Age >80 years or AAA size >5.5 cm did not increase the risk of reintervention. No specific AAA size, patient age, or combination thereof was identified that would contraindicate AAA repair.
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Affiliation(s)
- Robert J Hye
- Department of Surgery, Southern California Permanente Medical Group, San Diego, CA
| | - Afra U Janarious
- Department of Surgery, Southern California Permanente Medical Group, San Diego, CA
| | - Priscilla H Chan
- Surgical Outcomes and Analysis, Kaiser Permanente, San Diego, CA
| | - Guy Cafri
- Surgical Outcomes and Analysis, Kaiser Permanente, San Diego, CA
| | - Robert W Chang
- Department of Surgery, The Permanente Medical Group, South San Francisco, CA
| | - Thomas F Rehring
- Department of Vascular Surgery, Colorado Permanente Medical Group, Denver, CO
| | - Nicolas A Nelken
- Department of Vascular Therapy, Hawaii Permanente Group, Honolulu, HI
| | - Bradley B Hill
- Department of Vascular Surgery, The Permanente Medical Group, Santa Clara, CA.
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20
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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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21
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Majd P, Ahmad W, Galas N, Brunkwall JS. Patients Older Than 80 Years Can Reach Their Normal Life Expectancy After Abdominal Aortic Aneurysm Repair: A Comparison Between Endovascular Aneurysm Repair and Open Surgery. J Endovasc Ther 2018; 25:247-251. [DOI: 10.1177/1526602818759757] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Payman Majd
- Department of Vascular and Endovascular Surgery, University Hospital of Cologne, Germany
| | - Wael Ahmad
- Department of Vascular and Endovascular Surgery, University Hospital of Cologne, Germany
| | - Noemi Galas
- Department of Vascular and Endovascular Surgery, University Hospital of Cologne, Germany
| | - Jan S. Brunkwall
- Department of Vascular and Endovascular Surgery, University Hospital of Cologne, Germany
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22
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O'Donnell TFX, Shean KE, Deery SE, Bodewes TCF, Wyers MC, O'Brien KL, Matyal R, Schermerhorn ML. A preoperative risk score for transfusion in infrarenal endovascular aneurysm repair to avoid type and cross. J Vasc Surg 2018; 67:442-448. [PMID: 28756046 PMCID: PMC5785583 DOI: 10.1016/j.jvs.2017.05.108] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 05/12/2017] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Preoperative type and cross are often routinely ordered before elective endovascular aneurysm repair (EVAR), but the cost of this practice is high, and transfusion is rare. We therefore aimed to stratify patients by their risk of transfusion to identify a cohort in whom a type and screen would be sufficient. METHODS We queried the targeted vascular module of the National Surgical Quality Improvement Program (NSQIP) for all elective EVARs from 2011 to 2015. We included only infrarenal aneurysms and excluded ruptured aneurysms and patients transfused within 72 hours preoperatively. Two-thirds of the cases were randomly assigned to a model derivation cohort and one third to a validation cohort. We created and subsequently validated a risk model for transfusion within the first 24 hours of surgery (including intraoperatively), using logistic regression. RESULTS Between 2011 and 2015, there were 4875 patients who underwent elective infrarenal EVAR, only 221 (4.5%) of whom received a transfusion within 24 hours of surgery. The frequency of transfusion during the study period declined monotonously from 6.5% in 2011 to 3.2% in 2015. The factors independently associated with transfusion were preoperative hematocrit <36% (odds ratio [OR], 3.4 [95% confidence interval, 2.1-5.4]; P < .001), aortic diameter (per centimeter increase: OR, 1.2 [1.03-1.4]; P = .02), preoperative dependent functional status (OR, 2.5 [1.1-5.5]; P = .03), and chronic obstructive pulmonary disease (OR, 1.7 [1.04-2.9]; P = .04). A risk prediction model based on these criteria produced a C statistic of 0.69 in the prediction cohort and 0.76 in the validation cohort and a Hosmer-Lemeshow goodness of fit of 0.62 and 0.14, respectively. A score of <3 of 9, corresponding to a <5% probability of transfusion, would avoid preoperative type and cross in 86% of patients. Of the 4203 patients (86%) with a hematocrit >36%, only 6 (0.1%) had a risk score of >3. CONCLUSIONS Perioperative transfusion for EVAR is becoming increasingly uncommon and is predicted well by a transfusion risk score or simply a hematocrit of <36%. Application of this risk score would avoid unnecessary type and cross in the majority of patients, leading to significant savings in both time and cost.
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Affiliation(s)
- Thomas F X O'Donnell
- 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
| | - Sarah E Deery
- 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
| | - Mark C Wyers
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Kerry L O'Brien
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Robina Matyal
- 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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Yang L, Liu J, Li Y. Femoral Artery Closure Versus Surgical Cutdown for Endovascular Aortic Repair: A Single-Center Experience. Med Sci Monit 2018; 24:92-99. [PMID: 29304034 PMCID: PMC5765710 DOI: 10.12659/msm.905350] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND To compare the outcome and complication rates of femoral artery closure and surgical cutdown for endovascular aortic repair procedures (EVAR). MATERIAL AND METHODS Patients underwent either percutaneous femoral artery closure (PA group) or surgical cutdown (SC group) for EVAR between July 2011 and June 2016 and EVAR procedures were used for all cases. Data on outcomes and complications were collected and compared. RESULTS The SC group contained 55 patients and the PA group contained 60 patients and the technical success rates were 100.0% and 98.0%, respectively. The mean operation time, time to ambulation, and postoperative hospital stay were significantly shorter in the PA group (P<0.01). The estimated intraoperative blood loss and wound pain scores were significantly higher in the SC group (P<0.01). However, the PA procedure was more expensive (P<0.01). The overall incidence rate of complications was higher in the SC group (P=0.026). CONCLUSIONS The PA technique had a high success rate, shorter operation time and hospital stay, and fewer wound complications compared to SC. Thus, PA might be the preferred choice for selected EVAR procedures.
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Affiliation(s)
- Lin Yang
- Department of Vascular Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China (mainland)
| | - Jianlin Liu
- Department of Vascular Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China (mainland)
| | - Yanzi Li
- Department of Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China (mainland)
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Kalra K, Arya S. A comparative review of open and endovascular abdominal aortic aneurysm repairs in the national operative quality improvement database. Surgery 2017; 162:979-988. [DOI: 10.1016/j.surg.2017.04.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 04/11/2017] [Indexed: 01/25/2023]
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Open and endovascular aneurysm repair in the Society for Vascular Surgery Vascular Quality Initiative. Surgery 2017; 162:1195-1206. [PMID: 28774487 DOI: 10.1016/j.surg.2017.06.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Accepted: 06/10/2017] [Indexed: 11/22/2022]
Abstract
The Society for Vascular Surgery Vascular Quality Initiative is a patient safety organization and a collection of procedure-based registries that can be utilized for quality improvement initiatives and clinical outcomes research. The Vascular Quality Initiative consists of voluntary participation by centers to collect data prospectively on all consecutive cases within specific registries which physicians and centers elect to participate. The data capture extends from preoperative demographics and risk factors (including indications for operation), through the perioperative period, to outcomes data at up to 1-year of follow-up. Additionally, longer-term follow-up can be achieved by matching with Medicare claims data, providing long-term longitudinal follow-up for a majority of patients within the Vascular Quality Initiative registries. We present the unique characteristics of the Vascular Quality Initiative registries and highlight important insights gained specific to open and endovascular abdominal aortic aneurysm repair.
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Fenestrated endovascular aneurysm repair among octogenarians at high and standard risk for open repair. J Vasc Surg 2017; 66:354-359. [DOI: 10.1016/j.jvs.2016.11.064] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Accepted: 11/29/2016] [Indexed: 11/22/2022]
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Tan TW, Eslami M, Rybin D, Doros G, Zhang WW, Farber A. Outcomes of endovascular and open surgical repair of ruptured abdominal aortic aneurysms in elderly patients. J Vasc Surg 2017; 66:64-70. [PMID: 28216354 DOI: 10.1016/j.jvs.2016.10.119] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Accepted: 10/24/2016] [Indexed: 12/17/2022]
Abstract
BACKGROUND Endovascular aneurysm repair (EVAR) is becoming the preferred treatment modality for patients with a ruptured abdominal aortic aneurysm (rAAA). Although the survival advantage of EVAR over open aortic repair (OAR) has been shown in some studies, it is unclear whether this benefit extends to elderly patients. We sought to evaluate the outcomes of rAAA repair in octogenarians. METHODS We reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) data set (2005-2014) to identify patients older than 80 years who were treated with EVAR and OAR for rAAA. Procedural trends were evaluated during the course of the study period. Perioperative outcomes including mortality, morbidity, and hospital length of stay (LOS) were compared. Multivariable regression models were used to identify predictors of perioperative mortality and morbidity. RESULTS Among 1048 elderly patients who underwent rAAA repair, 450 (43%) and 598 (57%) were treated with EVAR and OAR, respectively. The use of EVAR to treat rAAA had increased significantly in this population of patients (0% in 2005 vs 56% in 2014; P < .001). The overall 30-day mortality rate among octogenarians was 41%. The mortality rate was significantly higher among those treated with OAR compared with EVAR (47% vs 33%; P < .001). Pneumonia (21% vs 10%; P < .001), reintubation (14% vs 9%; P < .001), and >48-hour ventilator dependence (43% vs 21%; P < .001) were significantly higher in patients undergoing OAR. Hospital LOS (13 vs 10 days; P < .001) was also longer in the OAR cohort. Compared with EVAR, OAR was independently predictive of 30-day mortality (adjusted odds ratio [AOR], 1.7; 95% confidence interval [CI], 1.3-2.2; P < .001), pneumonia (AOR, 2.4; 95% CI, 1.7-3.6; P < .001), >48-hour ventilator dependence (AOR, 2.5; 95% CI, 1.8-3.3; P < .001), and longer LOS (adjusted mean ratio, 1.4; 95% CI, 1.2-1.6; P < .001). CONCLUSIONS Elderly patients have significant but acceptable perioperative mortality and morbidity after rAAA repair. Use of endovascular repair in the elderly population has increased and is associated with better perioperative survival and 30-day outcomes compared with traditional open repair in this study.
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Affiliation(s)
- Tze-Woei Tan
- Division of Vascular Surgery, University of Arizona, Tucson, Ariz.
| | - Mohammad Eslami
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Denis Rybin
- Department of Biostatistics, Boston University School of Public Health, Boston, Mass
| | - Gheorghe Doros
- Department of Biostatistics, Boston University School of Public Health, Boston, Mass
| | - Wayne W Zhang
- Division of Vascular Surgery, Louisiana State University Health Sciences Center, Shreveport, La
| | - Alik Farber
- Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston, Mass
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Uehara K, Matsuda H, Inoue Y, Omura A, Seike Y, Sasaki H, Kobayashi J. Is Conventional Open Repair for Abdominal Aortic Aneurysm Feasible in Nonagenarians? Ann Vasc Dis 2017; 10. [PMID: 29147161 PMCID: PMC5684160 DOI: 10.3400/avd.oa.17-00013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Background: Although endovascular repair for abdominal aortic aneurysm has been found to be beneficial in very elderly patients, some patients have contraindications to this procedure. For nonagenarians, the results of open repair remain unclear. The purpose of this study was to compare the outcomes of open vs. endovascular repair for abdominal aortic aneurysm in nonagenarian patients. Methods and Results: Fourteen patients undergoing open surgical repair and 24 undergoing endovascular repair for abdominal aortic aneurysm were evaluated. There was no significant difference in early mortality between the open and endovascular groups (0% vs. 4.1%, p=0.16). The open repair group required much longer hospital stays (26.4 vs. 10.6 days, respectively, p=0.003). Finally, 12 patients (86%) undergoing open repair vs. 21 (88%) undergoing endovascular repair returned home (p=0.49). During a mean follow-up period of 23.4±23.5 months, cumulative estimated 1- and 3-year survival rates were 90.0% and 48.0%, respectively in the open repair group and 90.6% and 54.9%, respectively in the endovascular repair group (p=0.51). Conclusion: Although endovascular repair for abdominal aortic aneurysm was superior in terms of recovery, the results of conventional open repair were acceptable even in nonagenarian patients. Open repair remains an alternative for patients with contraindications to endovascular repair.
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Affiliation(s)
- Kyokun Uehara
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hitoshi Matsuda
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yosuke Inoue
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Atsushi Omura
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yoshimasa Seike
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hiroaki Sasaki
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Junjiro Kobayashi
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Japan
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Aitken SJ, Naganathan V, Blyth FM. Aortic aneurysm trials in octogenarians: Are we really measuring the outcomes that matter? Vascular 2016. [DOI: 10.1177/1708538115597079] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Purpose This study is a systematic review to determine the types of outcomes reported in abdominal aortic aneurysm (AAA) studies of patients aged 80 and over. Specifically, it determines the types of patient-centered outcomes reported. Method MEDLINE and EMBASE were searched from 2000 to 2014 for studies on AAA surgery with outcome data on patients aged 80 and over. Outcomes were categorized according to Donabedian’s framework for health quality indicators, with further classification as procedural, complication, resource or patient-centered outcome indicators. Findings Forty studies were reviewed. Patient-centered outcomes were infrequently reported (13%, n=5), with limited outcomes specifically relevant to older patients. No studies reported physical function, activities of daily living or cognition using validated assessment methods. Short-term mortality (95%, n=38) and complications (85%, n=34) were reported most frequently. Conclusion Reporting of aortic surgery outcomes in patients aged 80 and over requires a focus upon outcomes of primary importance to people of this age.
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Affiliation(s)
- SJ Aitken
- Concord Clinical School, Professorial Surgery Unit, Department of Vascular Surgery, New South Wales, Australia
| | - V Naganathan
- Concord Clinical School, Centre for Education and Research on Ageing, Concord, Sydney, New South Wales, Australia
| | - FM Blyth
- Concord Clinical School, Faculty of Medicine, University of Sydney, Sydney, New South Wales, Australia
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Abstract
Background: Literature on postoperative outcomes following aortic surgery for aortic graft infection (AGI) is limited by relatively small sample sizes, resulting in lack of national benchmarks for quality of care. We report in-hospital outcomes following abdominal aortic surgery for AGI and identify factors associated with postoperative complications using the Nationwide Inpatient Sample (NIS) database. Methods: Patients who underwent aortic graft resection for AGI were identified from the 2002 to 2008 NIS database, a multicenter database capturing 20% of all US admissions. Multivariable logistic regression analyses were performed. Results: Among 394 patients (men: 73.4%) who underwent abdominal aortic surgery for AGI, 53% of the admissions were emergent/urgent. A significant trend for decreasing number of abdominal aortic surgery for AGIs per year was observed (Pearson r correlation: −.96; P = .0006). Over the same time span, a significant correlation was also seen with decrease in open and increase in endovascular aortic aneurysm repairs in the NIS database. In-hospital rates of overall postoperative morbidity and mortality were 68.3% and 19.8%, respectively. In-hospital rates of postoperative respiratory failure, renal failure, and cardiac arrest were 35.5%, 14.2%, and 8.9%, respectively. Median length of stay was 26 days, with median hospital charges being US$184 162. On multivariable analysis, increase in age per year (odds ratio [OR] 1.07; 95% confidence interval [CI]: 1.03-1.12) was independently associated with postoperative morbidity, while higher hospital volume for this procedure was protective (OR: 0.71; 95% CI: 0.56-0.89). No preoperative factors were independently associated with postoperative mortality. Conclusion: Incidence of abdominal aortic surgery for AGI has progressively declined over the span of our study in association with decreased open and increased endovascular aortic aneurysm repairs. Aortic surgery for AGI is associated with very high morbidity and mortality rates along with prolonged lengths of stay and elevated hospital charges. The outcomes of operations for AGI are better in younger patients and higher volume hospitals.
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Silveira D, Pitoulias G, Torsello G, Donas KP. Outcomes of total endovascular treatment of juxtarenal aortic aneurysms in octogenarians. J Vasc Surg 2016; 63:909-14. [DOI: 10.1016/j.jvs.2015.10.094] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Accepted: 10/21/2015] [Indexed: 10/22/2022]
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Liu GP, Xue FS, Sun C, Li RP. Association of Perioperative Transfusion with 30-Day Morbidity and Mortality after Vascular Surgery: Re: Valentijn TM, et al. The impact of perioperative red blood cell transfusions on postoperative outcomes in vascular surgery patients. Ann Vasc Surg 2015; 29:511-9. Ann Vasc Surg 2015; 31:252-3. [PMID: 26597234 DOI: 10.1016/j.avsg.2015.09.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Accepted: 09/01/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Gao-Pu Liu
- Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fu-Shan Xue
- Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Chao Sun
- Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Rui-Ping Li
- Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Endofugas tipo 2 en una población tratada con endoprótesis Gore® Excluder: incidencia, persistencia y crecimiento del saco aneurismático. ANGIOLOGIA 2015. [DOI: 10.1016/j.angio.2015.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Morisaki K, Matsumoto T, Matsubara Y, Inoue K, Aoyagi Y, Matsuda D, Tanaka S, Okadome J, Maehara Y. Elective endovascular vs. open repair for abdominal aortic aneurysm in octogenarians. Vascular 2015. [PMID: 26223528 DOI: 10.1177/1708538115594967] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE The purpose of this study was to investigate the operative mortality and short-term and midterm outcomes of treatment of abdominal aortic aneurysm in Japanese patients over 80 years of age. METHODS Between January 2007 and December 2011, 207 patients underwent elective repair of infrarenal abdominal aortic aneurysms. Comorbidities, operative morbidity and mortality, midterm outcomes were analyzed retrospectively. RESULTS The average age (endovascular aneurysm repair, 84.4 ± 0.3; open, 82.8 ± 0.3, P < 0.01) and the percentage of hostile abdomen (endovascular aneurysm repair, 22.2%; open repair, 11.1%, P < 0.05) were higher in the endovascular aneurysm repair group. Percentage of outside IFU was higher in open repair (endovascular aneurysm repair, 38.5%; open repair, 63.3%, P < 0.01). The cardiac complication (endovascular aneurysm repair, 0%; open repair, 5.6%, P < 0.01) and length of postoperative hospital stay (endovascular aneurysm repair, 10.3 ± 0.8 days; open, 18.6 ± 1.6 days, P < 0.05) were significantly lower in the endovascular aneurysm repair group. There were no differences in operative mortality (endovascular aneurysm repair, 0%; open, 1.1%, P = 0.43) and the aneurysm-related death was not observed. The rate of secondary interventions (EVAR, 5.1%; open repair, 0%, P < 0.01) and midterm mortality rate were much higher in the endovascular aneurysm repair group. CONCLUSIONS Endovascular aneurysm repair is less invasive than open repair and useful for treating abdominal aortic aneurysm in octogenarians; however, open repair can be acceptable treatment in the inappropriate case treated by endovascular aneurysm repair.
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Affiliation(s)
- Koichi Morisaki
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takuya Matsumoto
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yutaka Matsubara
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kentaro Inoue
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yukihiko Aoyagi
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Daisuke Matsuda
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shinichi Tanaka
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Jun Okadome
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yoshihiko Maehara
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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St-Louis E, Sudarshan M, Al-Habboubi M, El-Husseini Hassan M, Deckelbaum DL, Razek TS, Feldman LS, Khwaja K. The outcomes of the elderly in acute care general surgery. Eur J Trauma Emerg Surg 2015; 42:107-13. [PMID: 26038035 DOI: 10.1007/s00068-015-0517-9] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2014] [Accepted: 03/11/2015] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Elderly patients form a growing subset of the acute care surgery (ACS) population. Older age may be associated with poorer outcomes for some elective procedures, but there are few studies focusing on outcomes for the elderly ACS population. Our objective is to characterize differences in mortality and morbidity for acute care surgery patients >80 years old. METHODS A retrospective review of all ACS admissions at a large teaching hospital over 1 year was conducted. Patients were classified into non-elderly (<80 years old) and elderly (≥80 years old). In addition to demographic differences, outcomes including care efficiency, mortality, postoperative complications, and length of stay were studied. Data analysis was completed with the Student's t test for continuous variables and Fisher's exact test for categorical variables using STATA 12 (College Station, TX, USA). RESULTS We identified 467 non-elderly and 60 elderly patients with a mean age-adjusted Charlson score of 3.2 and 7.2, respectively (p < 0.001) and a mortality risk of 1.9 and 11.7 %, respectively (p < 0.001). The elderly were at risk of longer duration (>4 days) hospital stay (p = 0.05), increased postoperative complications (p = 0.002), admission to the ICU (p = 0.002), and were more likely to receive a non-operative procedure (p = 0.003). No difference was found (p = NS) for patient flow factors such as time to consult general surgery, time to see consult by general surgery, and time to operative management and disposition. CONCLUSIONS Compared to younger patients admitted to an acute care surgery service, patients over 80 years old have a higher risk of complications, are more likely to require ICU admission, and stay longer in the hospital.
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Affiliation(s)
- E St-Louis
- Division of General Surgery, Montreal General Hospital, 1650 Cedar Ave, Montreal, QC, H3G 1A4, Canada.
| | - M Sudarshan
- Division of General Surgery, Montreal General Hospital, 1650 Cedar Ave, Montreal, QC, H3G 1A4, Canada.
| | - M Al-Habboubi
- Division of General Surgery, Montreal General Hospital, 1650 Cedar Ave, Montreal, QC, H3G 1A4, Canada.
| | - M El-Husseini Hassan
- Division of General Surgery, Montreal General Hospital, 1650 Cedar Ave, Montreal, QC, H3G 1A4, Canada.
| | - D L Deckelbaum
- Division of General Surgery, Montreal General Hospital, 1650 Cedar Ave, Montreal, QC, H3G 1A4, Canada.
| | - T S Razek
- Division of General Surgery, Montreal General Hospital, 1650 Cedar Ave, Montreal, QC, H3G 1A4, Canada.
| | - L S Feldman
- Division of General Surgery, Montreal General Hospital, 1650 Cedar Ave, Montreal, QC, H3G 1A4, Canada.
| | - K Khwaja
- Division of General Surgery, Montreal General Hospital, 1650 Cedar Ave, Montreal, QC, H3G 1A4, Canada.
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de Leur K, Flu HC, Ho GH, de Groot HG, Veen EJ, van der Laan L. Outcome of elective treatment of abdominal aortic aneurysm in elderly patients. Int J Surg 2015; 15:117-23. [DOI: 10.1016/j.ijsu.2015.02.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Revised: 01/31/2015] [Accepted: 02/03/2015] [Indexed: 11/30/2022]
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Hughes K, Abdulrahman H, Prendergast T, Rose DA, Ongu'ti S, Tran D, Cornwell EE, Obisesan T, Amankwah KS. Abdominal Aortic Aneurysm Repair in Nonagenarians. Ann Vasc Surg 2015; 29:183-8. [DOI: 10.1016/j.avsg.2014.07.037] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Revised: 06/12/2014] [Accepted: 07/30/2014] [Indexed: 11/28/2022]
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Miranda SDP, Miranda PC, Volpato MG, Folino MC, Kambara AM, Rossi FH, Izukawa NM. Open vs. endovascular repair of abdominal aortic aneurysm: a comparative analysis. J Vasc Bras 2014. [DOI: 10.1590/1677-5449.0118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Context:Abdominal aortic aneurysm (AAA) is a condition that is usually asymptomatic, but potentially fatal, and has a prevalence in men over 60 years old ranging from 4.3% to 8%. There are two treatment options available: open surgery (OS) and endovascular treatment (ET).Objective:To compare the results of repairs conducted using these two treatment methods from 2008 to 2013 in a tertiary hospital.Methods:A retrospective analysis comparing 119 patients treated with OS and 219 patients who underwent ET for AAA repair.Results:The ET group was older (71.3 vs. 68.2 years; p<0.001) and had a higher rate of coronary disease (44.7% vs. 27.7%; p=0.002) and a lower ejection fraction (57.6% vs. 64.3%; p<0.001); in turn, the OS group had more chronic obstructive pulmonary disease (16.0% vs. 5.9%; p=0.004) and a smaller proximal infrarenal neck (15.5 mm vs. 23.0 mm; p<0.001). However, there was no difference in ASA classification (American Society of Anesthesiology) (p=0.36). The ET group had less intraoperative bleeding (171 mL vs. 729 mL; p<0.001) and required fewer blood transfusions (11.9% vs. 73.1% p<0.001), and spent shorter stays in both ICU (2.4 vs. 3.5 days; p=0.002) and hospital (5.8 vs. 10.3 days; p<0.001). Thirty-day mortality was similar (OS 5.0% vs. ET 4.1%; p=0.78) and there was also no difference in postoperative complications. The average cost of ET was higher (R$34,277.76 vs. R$4,778.60; p<0.001).Conclusions:Rates of morbidity and mortality were similar, although ET was associated with less bleeding, fewer transfusions and shorter hospital stays, but was more expensive.
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Coscas R, Dennery M, Javerliat I, Di Centa I, Cudennec T, Teillet L, Goëau-Brissonniere O, Coggia M. Laparoscopy versus EVAR for the Treatment of Abdominal Aortic Aneurysms in the Octogenarian. Ann Vasc Surg 2014; 28:1634-41. [DOI: 10.1016/j.avsg.2014.04.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2013] [Revised: 03/16/2014] [Accepted: 04/20/2014] [Indexed: 01/25/2023]
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Hertault A, Sobocinski J, Kristmundsson T, Maurel B, Dias NV, Azzaoui R, Sonesson B, Resch T, Haulon S. Results of F-EVAR in Octogenarians. Ann Vasc Surg 2014; 28:1396-401. [DOI: 10.1016/j.avsg.2014.02.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2013] [Revised: 01/06/2014] [Accepted: 02/04/2014] [Indexed: 11/16/2022]
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Yuo TH, Sidaoui J, Marone LK, Avgerinos ED, Makaroun MS, Chaer RA. Limited survival in dialysis patients undergoing intact abdominal aortic aneurysm repair. J Vasc Surg 2014; 60:908-13.e1. [PMID: 24854417 DOI: 10.1016/j.jvs.2014.04.050] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Accepted: 04/16/2014] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Elective abdominal aortic aneurysm (AAA) repair in suitable candidates is a standard modality. The outcomes of AAA repair in patients with end-stage renal disease on dialysis are not well characterized, and there is questionable survival advantage in such patients with limited life expectancy. We sought to describe outcomes after AAA repair in U.S. dialysis patients. METHODS The United States Renal Data System was used to collect data on intact asymptomatic AAA repair procedures in dialysis patients in the United States between 2005 and 2008. Endovascular AAA repair (EVAR) and open aortic repair (OAR) were identified by Current Procedural Terminology codes. Primary outcomes were perioperative (30-day) mortality and long-term survival. Predictors of mortality were identified by multivariate regression models. RESULTS A total of 1557 patients were identified who had undergone elective AAA repair: 261 OAR and 1296 EVAR. The 30-day mortality was 11.3% (EVAR, 10.3%; OAR, 16.1%; P = .010), with increased age associated with increased mortality (odds ratio, 1.04; 95% confidence interval [CI], 1.02-1.07; P = .001). Kaplan-Meier survival estimates were 66.5% at 1 year (EVAR, 66.2%; OAR, 68%) and 37.4% at 3 years (EVAR, 36.8%; OAR, 40%; P = .33). Median survival was 25.3 months after EVAR and 27.4 months after OAR. Women had a higher mortality rate at 1 year (38.7%) compared with men (32.0%) (P = .015). There was no significant mortality difference at 1 year in comparing type of procedure in both men (EVAR, 31.6%; OAR, 34%; P = .55) and women (EVAR, 39.3%; OAR, 36%; P = .60). A Cox proportional hazards model demonstrated that male gender (hazard ratio [HR], 0.75; 95% CI, 0.62-0.92; P = .005), increased time on dialysis (HR for each year on dialysis, 0.79; 95% CI, 0.75-0.83; P < .001), kidney transplantation history (HR, 0.62; 95% CI, 0.43-0.88; P = .008), and diagnosis of hypertension (HR, 0.60; 95% CI, 0.48-0.75; P < .001) were protective against mortality. Increased age (HR, 1.02; 95% CI, 1.01-1.03; P < .001) and diabetes diagnosis (HR, 1.39; 95% CI, 1.13-1.71; P = .002) predicted increased mortality. CONCLUSIONS AAA patients on dialysis have high perioperative and 1-year mortality rates after EVAR or OAR, particularly diabetics, women, and the elderly. This raises questions about the indications for intact AAA repair in dialysis patients, in whom the size threshold may need to be raised. Dialysis patients may be best served by deferring repair of AAA until AAAs reach large size or become symptomatic, especially if OAR is required, given the higher perioperative mortality compared with EVAR.
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Affiliation(s)
- Theodore H Yuo
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Joseph Sidaoui
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Luke K Marone
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Efthymios D Avgerinos
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Michel S Makaroun
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Rabih A Chaer
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa.
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Open versus Endovascular Repair of Abdominal Aortic Aneurysm in the Elective and Emergent Setting in a Pooled Population of 37,781 Patients: A Systematic Review and Meta-Analysis. ISRN CARDIOLOGY 2014; 2014:149243. [PMID: 25006502 PMCID: PMC4004021 DOI: 10.1155/2014/149243] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Accepted: 02/03/2014] [Indexed: 01/09/2023]
Abstract
Background. We evaluated the incidence of mortality and myocardial infarction (MI) in endovascular repair (EVAR) as compared to open aneurysm repair (OAR) in both elective and ruptured abdominal aortic aneurysm (AAA ) setting. Methods. We analyzed the rates of 30-day mortality, 30-day MI, and hospital length of stay (LOS) based on comparative observation and randomized control trials involving EVAR and OAR. Results. 41 trials compared EVAR to OAR with a total pooled population of 37,781 patients. Analysis of elective and ruptured AAA repair favored EVAR with respect to 30-day mortality with a pooled odds ratio of 0.19 (95% CI 0.17–0.20; I2 = 88.9%; P < 0.001). There were a total of 1,835 30-day MI events reported in the EVAR group as compared to 2,483 events in the OAR group. The pooled odds ratio for elective AAA was 0.74 (95% CI 0.58–0.96; P = 0.02) in favor of EVAR. The average LOS was reduced by 296.75 hrs (95% CI 156.68–436.82 hrs; P < 0.001) in the EVAR population. Conclusions. EVAR has lower rates of 30-day mortality, 30-day MI, and LOS in both elective and ruptured AAA repair.
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Pratesi C, Piffaretti G, Pratesi G, Castelli P. ITalian Excluder Registry and results of Gore Excluder endograft for the treatment of elective infrarenal abdominal aortic aneurysms. J Vasc Surg 2014; 59:52-7.e1. [DOI: 10.1016/j.jvs.2013.06.067] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2013] [Revised: 06/14/2013] [Accepted: 06/18/2013] [Indexed: 11/29/2022]
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What is the Best Option for Elective Repair of an Abdominal Aortic Aneurysm in a Young Fit Patient? Eur J Vasc Endovasc Surg 2014; 47:13-8. [DOI: 10.1016/j.ejvs.2013.09.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Accepted: 09/11/2013] [Indexed: 11/19/2022]
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Vallabhaneni R, Farber MA, Schneider F, Ricco JB. Debate: Whether young, good-risk patients should be treated with endovascular abdominal aortic aneurysm repair. J Vasc Surg 2013; 58:1709-15. [DOI: 10.1016/j.jvs.2013.09.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Part Two: Against the Motion. Young Patients with Good Risk Factors Should not be Treated with EVAR. Eur J Vasc Endovasc Surg 2013; 46:618-21. [DOI: 10.1016/j.ejvs.2013.09.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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de Blic R, Alsac JM, Julia P, El Batti S, Mirault T, Di Primio M, Sapoval M, Messas E, Fabiani JN. Elective treatment of abdominal aortic aneurysm is reasonable in patients >85 years of age. Ann Vasc Surg 2013; 28:209-16. [PMID: 24084274 DOI: 10.1016/j.avsg.2013.01.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2012] [Revised: 12/03/2012] [Accepted: 01/12/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND The numbers of patients >85 years of age referred for abdominal aortic aneurysm (AAA) repair have increased in recent decades. With the population aging, increased screening of AAA, and introduction of less invasive surgical techniques, vascular surgeons will be treating more elderly patients. Few data are available for estimating the risks and benefits of prophylactic repair among those with such an advanced age. The aim of this single-center study was to evaluate the short-term to midterm results after AAA repair in patients >85 years of age. METHODS Between 2004 and 2012, data of patients >85 years old who required an elective AAA repair at our institution were collected prospectively. According to the current guidelines, patients underwent endovascular aneurysm repair (EVAR) each time the aortic anatomy was suitable. Open repair (OR) was performed in those patients with hostile proximal neck anatomy and/or severe iliac tortuosity. Type of repair (EVAR or OR) and perioperative and midterm outcomes were analyzed. Primary end points were 30-day mortality and midterm survival. RESULTS Among 1016 patients undergoing elective AAA repair during the study period, 59 (5.8%) were ≥85 years of age (54 men, mean age 87 ± 2 years), with a mean aneurysm diameter of 61.5 ± 20.3 mm. Thirty-three patients (56%) underwent EVAR and 26 (44%) had an OR. Thirty-day mortality was 6.7% (6% with EVAR and 7.6% with OR, P <0.05). Mean follow-up was 24.7 ± 18 months. Kaplan‒Meier analyses for survival were 85.5%, 64.5%, and 50% at 1, 3, and 5 years, respectively. No aneurysm-related death was observed during follow-up. CONCLUSION Elective repair may be proposed in patients >85 years of age in cases of threatening AAA, showing acceptable perioperative mortality and reasonable midterm survival results. Even if EVAR did not seem to offer significant benefits in perioperative mortality in our study, it appears reasonable to suggest this less invasive technique as first-line treatment in cases of suitable anatomy in such an advanced-age population.
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Affiliation(s)
- Romain de Blic
- Department of Cardiac and Vascular Surgery, Hôpital Européen Georges-Pompidou, Aphp, Faculte René Descartes, Paris, France
| | - Jean-Marc Alsac
- Department of Cardiac and Vascular Surgery, Hôpital Européen Georges-Pompidou, Aphp, Faculte René Descartes, Paris, France.
| | - Pierre Julia
- Department of Cardiac and Vascular Surgery, Hôpital Européen Georges-Pompidou, Aphp, Faculte René Descartes, Paris, France
| | - Salma El Batti
- Department of Cardiac and Vascular Surgery, Hôpital Européen Georges-Pompidou, Aphp, Faculte René Descartes, Paris, France
| | - Tristan Mirault
- Department of Vascular Medecine, Hôpital Européen Georges-Pompidou, Aphp, Faculte René Descartes, Paris, France
| | - Maximiliano Di Primio
- Department of Interventional Radiology, Hôpital Européen Georges-Pompidou, Aphp, Faculte René Descartes, Paris, France
| | - Marc Sapoval
- Department of Interventional Radiology, Hôpital Européen Georges-Pompidou, Aphp, Faculte René Descartes, Paris, France
| | - Emmanuel Messas
- Department of Vascular Medecine, Hôpital Européen Georges-Pompidou, Aphp, Faculte René Descartes, Paris, France
| | - Jean-Noël Fabiani
- Department of Cardiac and Vascular Surgery, Hôpital Européen Georges-Pompidou, Aphp, Faculte René Descartes, Paris, France
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Trenner M, Haller B, Söllner H, Storck M, Umscheid T, Niedermeier H, Eckstein HH. 12 Jahre „Qualitätssicherung BAA“ der DGG. GEFASSCHIRURGIE 2013. [DOI: 10.1007/s00772-013-1159-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Stather PW, Sidloff D, Dattani N, Choke E, Bown MJ, Sayers RD. Systematic review and meta-analysis of the early and late outcomes of open and endovascular repair of abdominal aortic aneurysm. Br J Surg 2013; 100:863-72. [DOI: 10.1002/bjs.9101] [Citation(s) in RCA: 249] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2013] [Indexed: 12/18/2022]
Abstract
Abstract
Background
Any possible long-term benefit from endovascular (EVAR) versus open surgical repair for abdominal aortic aneurysm (AAA) remains unproven. Long-term data from the Open Versus Endovascular Repair (OVER) trial add to the debate regarding long-term all-cause and aneurysm-related mortality. The aim of this study was to investigate 30-day and long-term mortality, reintervention, rupture and morbidity after EVAR and open repair for AAA in a systematic review.
Methods
Standard PRISMA guidelines were followed. Random-effects Mantel–Haenszel meta-analysis was performed to evaluate mortality and morbidity outcomes.
Results
The existing published randomized trials, together with information from Medicare and SwedVasc databases, were included in a meta-analysis. This included 25 078 patients undergoing EVAR and 27 142 undergoing open repair for AAA. Patients who had EVAR had a significantly lower 30-day or in-hospital mortality rate (1·3 per cent versus 4·7 per cent for open repair; odds ratio (OR) 0·36, 95 per cent confidence interval 0·21 to 0·61; P < 0·001). By 2-year follow-up there was no difference in all-cause mortality (14·3 versus 15·2 per cent; OR 0·87, 0·72 to 1·06; P = 0·17), which was maintained after at least 4 years of follow-up (34·7 versus 33·8 per cent; OR 1·11, 0·91 to 1·35; P = 0·30). There was no significant difference in aneurysm-related mortality by 2 years or longer follow-up. A significantly higher proportion of patients undergoing EVAR required reintervention (P = 0·003) and suffered aneurysm rupture (P < 0·001).
Conclusion
There is no long-term survival benefit for patients who have EVAR compared with open repair for AAA. There are also significantly higher risks of reintervention and aneurysm rupture after EVAR.
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Affiliation(s)
- P W Stather
- Vascular Surgery Group, Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - D Sidloff
- Vascular Surgery Group, Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - N Dattani
- Vascular Surgery Group, Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - E Choke
- Vascular Surgery Group, Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - M J Bown
- Vascular Surgery Group, Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- Leicester National Institute for Health Research Cardiovascular Biomedical Research Unit, Leicester, UK
| | - R D Sayers
- Vascular Surgery Group, Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
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Sharifpour M, Moore LE, Shanks AM, Didier TJ, Kheterpal S, Mashour GA. Incidence, Predictors, and Outcomes of Perioperative Stroke in Noncarotid Major Vascular Surgery. Anesth Analg 2013; 116:424-34. [DOI: 10.1213/ane.0b013e31826a1a32] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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