1
|
Borgen L, Aasekjær K, Skoe ØW. Exploiting endovascular aortic repair as a minimally invasive method - Nine years of experience in a non-university hospital. Eur J Radiol Open 2023; 11:100522. [PMID: 37701925 PMCID: PMC10493885 DOI: 10.1016/j.ejro.2023.100522] [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: 02/02/2023] [Revised: 08/22/2023] [Accepted: 09/02/2023] [Indexed: 09/14/2023] Open
Abstract
Background At the introduction of endovascular aortic repair (EVAR) in 2013 in our non-university hospital, we established a quality registry to monitor our EVAR activity. Purpose To observe if we over time were able to exploit EVAR as a minimally invasive method in an elective as well as emergency setting, and to monitor our treatment quality in terms of complications, secondary interventions and mortality. Material and methods From November 2013 to March 2022, we treated 207 patients with EVAR, including six patients with rupture. Follow-up regimen was partly based on contrast-enhanced computer tomography, and partly on contrast-enhanced ultrasound in combination with plain radiography. Results During the observation period, the method of anesthesia changed from general, via spinal, to local anesthesia. The groin access changed from surgical cut down to percutaneous and the median length of postoperative stay decreased from 3 days to 1 day. EVAR on ruptured aneurysm was done for the first time in 2019. Endoleak was detected in 85 patients (42%) and 37 patients (18%) had one or more secondary interventions, of which 85% were endovascular. Estimated five-year survival was 72% in patients below 80 years of age and 45% in patients 80 years or older. Conclusion Nine years of experience enabled us to exploit EVAR's advantages as a minimally invasive method in an elective as well as emergency setting. Complications, secondary interventions and survival rates in our low volume non-university hospital matches results from larger vascular centers.
Collapse
Affiliation(s)
- Lars Borgen
- Department of Radiology, Drammen Hospital, Vestre Viken Health Trust, Dronning gaten 28, 3004 Drammen, Norway
| | - Kjartan Aasekjær
- Department of Radiology, Drammen Hospital, Vestre Viken Health Trust, Dronning gaten 28, 3004 Drammen, Norway
| | - Øyvind Werpen Skoe
- Department of Surgery, Drammen Hospital, Vestre Viken Health Trust, Dronning gaten 28, 3004 Drammen, Norway
| |
Collapse
|
2
|
Cirillo-Penn NC, Zheng X, Mao J, Johnston LE, D’Oria M, Scali S, Goodney PP, DeMartino RR. Long-term Mortality and Reintervention After Repair of Ruptured Abdominal Aortic Aneurysms Using VQI-matched Medicare Claims. Ann Surg 2023; 278:e1135-e1141. [PMID: 37057613 PMCID: PMC10576015 DOI: 10.1097/sla.0000000000005876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/15/2023]
Abstract
OBJECTIVE The objective of this study was to compare endovascular aortic aneurysm repair (EVAR) versus open aortic repair (OAR) on mortality and reintervention after ruptured infrarenal abdominal aortic aneurysm (rAAA) repair in the Vascular Quality Initiative (VQI). BACKGROUND The optimal treatment modality for rAAA remains debated, with little data on long-term comparisons. METHODS VQI rAAA repairs (2004-2018) were matched with Medicare claims (VQI-VISION). Primary outcomes were in-hospital and long-term mortality. Secondary outcome was reintervention. Inverse probability weighting was used to adjust for treatment selection, and Cox Proportional Hazards models and negative binomial regressions were used for analysis. Landmark analysis was performed among patients surviving hospital discharge. RESULTS Among 1885 VQI/Medicare rAAA patients, 790 underwent OAR, and 1095 underwent EVAR. Median age was 76 years; 73% were male. Inverse probability weighting produced comparable groups. In-hospital mortality was lower after EVAR versus OAR (21% vs 37%, odds ratio: 0.52, 95% CI, 0.4-0.7). One-year mortality rates were lower for EVAR versus OAR [hazard ratio (HR) 0.74, 95% CI, 0.6-0.9], but not statistically different after 1 year (HR: 0.95, 95% CI, 0.8-1.2). This implies additional benefits to EVAR in the short term. Reintervention rates were higher after EVAR than OAR at 2 and 5 years (rate ratio: 1.79 95% CI, 1.2-2.7 and rate ratio:2.03 95% CI, 1.4-3.0), but not within the first year. Reintervention was associated with higher mortality risk for both OAR (HR: 1.66 95% CI, 1.1-2.5) and EVAR (HR: 2.14 95% CI, 1.6-2.9). Long-term mortality was similar between repair types (HR: 0.99, 95% CI, 0.8-1.2). CONCLUSIONS Within VQI/Medicare patients undergoing rAAA repair, the perioperative mortality rate favors EVAR but equalizes after 1 year. Reinterventions were more common after EVAR and were associated with higher mortality regardless of treatment.
Collapse
Affiliation(s)
| | - Xinyan Zheng
- Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, NY
| | - Jialin Mao
- Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, NY
| | - Lily E. Johnston
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester MN, USA
| | - Mario D’Oria
- Division of Vascular and Endovascular, Cardiovascular Department, Trieste University Hospital ASUIGI, Trieste, Italy
| | - Salvatore Scali
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL
| | - Philip P. Goodney
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | | | | |
Collapse
|
3
|
Long-term Survival After Repair of Ruptured Abdominal Aortic Aneurysms Is Improving Over Time: Nationwide Analysis During Twenty-four Years in Sweden (1994-2017). Ann Surg 2023; 277:e670-e677. [PMID: 34183511 DOI: 10.1097/sla.0000000000005030] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To investigate long-term survival after ruptured abdominal aortic aneurysms (rAAA) repair in Sweden during twenty-four years (1994-2017). SUMMARY BACKGROUND DATA Management of rAAA has seen significant changes in the past decades, with the shifting from open (OAR) to endovascular (EVAR) being the most striking, thereby enabling treatment of elderly patients with multiple comorbidities. METHODS A registry-based nationwide cohort study was performed, and three 8-year periods (1994-2001, 2002-2009, 2010-2017) were compared for crude long-term survival with Kaplan-Meier and multivariable Cox proportional hazards analyses. Relative survival compared to matched general population referents was estimated. RESULTS Overall, 8928 rAAA repair subjects were identified (1994-2001 N = 3368; 2002-2009 N = 3405; 2010-2017 N = 2155). The proportion of octogenarians (20.6%; 27.5%; 34.0%; P < 0.001), women (14.3%; 18.5%; 20.6%; P < 0.001), and EVAR procedures (1.5%; 14.9%; 35.5%; P < 0.001) increased over time. The crude 5-year survival was 36%; 44%; 43% (P < 0.0001). Multivariable Cox proportional hazard analysis displayed a decreasing mortality hazard ratio (HR) over time (1.00; 0.80; 0.72; P < 0.001). Use of EVAR was associated with reduced hazards of crude long-term mortality (HR = 0.80, P < 0.001). Relative survival for patients surviving the perioperative period (ie, 90 days) was lower than matched general population referents, and was stable over time (relative 5-year survival: 86% vs 88%, vs 86% P < 0.001). CONCLUSIONS Nationwide analysis of long-term outcomes after repair of rAAA in Sweden during 24 years (1994-2017) has revealed that, despite changes in the baseline population characteristics as well as in the treatment strategy, long-term survival improved over time.
Collapse
|
4
|
Center Volume and Failure to Rescue after Open or Endovascular Repair of Ruptured Abdominal Aortic Aneurysms. J Vasc Surg 2022; 76:1565-1576.e4. [PMID: 35872329 DOI: 10.1016/j.jvs.2022.05.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 04/26/2022] [Accepted: 05/05/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND The correlation between center volume and elective abdominal aortic aneurysm(AAA) repair outcomes is well established; however, these effects for either endovascular(EVAR) or open(OAR) repair of ruptured AAA(rAAA) remains unclear. Notably, the capacity to either avert or manage complications associated with postoperative mortality is an important cause of outcome disparities following elective procedures; however, there is a paucity of data surrounding non-elective presentations. Therefore, the purpose of this analysis was to describe the association between annual center volume, complications, and failure to rescue(FtR) after EVAR and OAR of rAAA. METHODS All consecutive endovascular and open rAAA repairs from 2010-2020 in the Vascular Quality Initiative were examined. Annual center volume(procedures/year per center) was grouped into quartiles: EVAR-Q1[<14](3.4%), Q2[14-23](12.8%), Q3[24-37](24.7%), Q4[>38](59.1%); OAR-Q1[<3](5.4%), Q2[4-6](12.8%), Q3[7-10](22.7%), Q4[>10](59.1%). The primary end-point was FtR, defined as in-hospital death after experiencing one of six major complications(cardiac, renal, respiratory, stroke, bleeding, colonic ischemia). Risk-adjusted analyses for inter-group comparisons was completed using multivariable logistic regression. RESULTS The unadjusted in-hospital death rate was 16.5% and 28.9% for EVAR and OAR, respectively. Complications occurred in 45% of EVAR(n=1,439/3,188) and 70% of OAR(n=1,366/1,961) patients with corresponding FtR rates of 14%(EVAR) and 26%(OAR). For OAR, Q4-centers had a 43% lower FtR risk(OR 0.57, 95%CI 0.4-0.9;p=.017) compared to Q1 centers. Centers performing >5 OARs/year had a 43% lower risk(OR 0.57, 95%CI 0.4-0.7;p<.001) of FtR and this decreased 4% for each additional 5 procedures performed annually(95%CI .93-.991;p=.013). However, there was no significant relationship between center volume and FtR after EVAR. The risk of FtR was strongly associated with a greater number of complications for both procedures(OR multiplied by 6.5 for EVAR and 1.5 for OAR for each additional complication;p<.0001). Among OAR patients with a single recorded complication, return to the operating room for bleeding had highest risk of in-hospital mortality(OR 4.1, 95%CI 1.1-4.8;p=.034), while no specific type of complication increased FtR risk after EVAR. CONCLUSIONS FtR occurs commonly after EVAR and OAR of rAAA within VQI centers. Importantly, increasing center volume was associated with reduced FtR risk after OAR but not EVAR. Complication pattern and frequency predicted FTR after either repair strategy. For stable patients, especially those deemed anatomically ineligible for EVAR, these findings emphasize the need to improve coordination of regional referral networks that centralize rAAAs to high-volume centers. Moreover, hospitals that treat rAAA should invest resources that develop protocols targeting specific complications to mitigate risk of preventable postoperative death.
Collapse
|
5
|
Maier-Hasselmann A, Modica F, Helmberger T. [Abdominal aortic aneurysms-open vs. endovascular treatment : Decision-making from the perspective of the vascular surgeon]. RADIOLOGIE (HEIDELBERG, GERMANY) 2022; 62:570-579. [PMID: 35737000 DOI: 10.1007/s00117-022-01021-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/24/2022] [Indexed: 06/15/2023]
Abstract
CLINICAL/METHODICAL ISSUE In the last 20 years, the treatment of abdominal aortic aneurysms has essentially evolved from surgical to minimally invasive endovascular treatment. ACHIEVEMENTS There are still a number of clinical situations that make surgical intervention useful or even necessary. This underlines the importance of interdisciplinary vascular centers for the treatment of complex aortic pathologies and their sequelae. PRACTICAL RECOMMENDATIONS In the following article, the arguments for the choice of procedure for the treatment of infrarenal aortic aneurysms are discussed and the recommendations of various guidelines are compared.
Collapse
Affiliation(s)
- Andreas Maier-Hasselmann
- Klinik für Gefäßchirurgie, vaskuläre und endovaskuläre Chirurgie, München Klinik Bogenhausen, 81925, München, Deutschland.
| | - Filippo Modica
- Klinik für Gefäßchirurgie, vaskuläre und endovaskuläre Chirurgie, München Klinik Bogenhausen, 81925, München, Deutschland
| | - Thomas Helmberger
- Institut für Radiologie, Neuroradiologie und minimal-invasive Therapie, München Klinik Bogenhausen, München, Deutschland
| |
Collapse
|
6
|
Vascular Deformation Mapping of Abdominal Aortic Aneurysm. ACTA ACUST UNITED AC 2021; 7:189-201. [PMID: 34067962 PMCID: PMC8162544 DOI: 10.3390/tomography7020017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 04/23/2021] [Accepted: 05/10/2021] [Indexed: 12/01/2022]
Abstract
Abdominal aortic aneurysm (AAA) is a complex disease that requires regular imaging surveillance to monitor for aneurysm stability. Current imaging surveillance techniques use maximum diameter, often assessed by computed tomography angiography (CTA), to assess risk of rupture and determine candidacy for operative repair. However, maximum diameter measurements can be variable, do not reliably predict rupture risk and future AAA growth, and may be an oversimplification of complex AAA anatomy. Vascular deformation mapping (VDM) is a recently described technique that uses deformable image registration to quantify three-dimensional changes in aortic wall geometry, which has been previously used to quantify three-dimensional (3D) growth in thoracic aortic aneurysms, but the feasibility of the VDM technique for measuring 3D growth in AAA has not yet been studied. Seven patients with infra-renal AAAs were identified and VDM was used to identify three-dimensional maps of AAA growth. In the present study, we demonstrate that VDM is able to successfully identify and quantify 3D growth (and the lack thereof) in AAAs that is not apparent from maximum diameter. Furthermore, VDM can be used to quantify growth of the excluded aneurysm sac after endovascular aneurysm repair (EVAR). VDM may be a useful adjunct for surgical planning and appears to be a sensitive modality for detecting regional growth of AAAs.
Collapse
|
7
|
Braet DJ, Taaffe JP, Singh P, Bath J, Kruse RL, Vogel TR. Readmission and Utilization After Repair of Ruptured Abdominal Aortic Aneurysms in the United States. Vasc Endovascular Surg 2020; 55:245-253. [PMID: 33353494 DOI: 10.1177/1538574420980578] [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: 11/17/2022]
Abstract
OBJECTIVES Endovascular aneurysm repair (EVAR) has emerged as a less invasive alternative to open repair for ruptured Abdominal Aortic Aneurysms (rAAA), but comparisons to traditional open rAAA repair and late complications leading to readmission are limited. MATERIALS AND METHODS Hospitalizations for patients undergoing repair for rAAA were selected from the Nationwide Readmissions Database (NRD). In-hospital mortality, complications, 30-day readmission, readmission diagnoses, and charges were evaluated. Design-adjusted chi-square, Wilcoxon test, and logistic regression were used for analysis. RESULTS During 2014-2016, 3,629 open rAAA and 5,037 EVAR were identified. The index mortality rate was 21.4% for EVAR vs. 33.5% for open (p < .0001). Median index length of stay (LOS) was 4.9 days for EVAR vs. 8.6 days for open repair (p < 0.001). All-cause 30-day readmission after rAAA was higher following EVAR (18.9%) than open (14.3%, p = .007). Time to readmission and charges for readmission stays did not differ between procedure groups. Respiratory complications were more common following open repair than EVAR (20.4% vs 11.4%, respectively; p = .008). Patients who underwent open repair suffered more infectious complications than patients treated with EVAR during readmission (49.2% vs 39.8%, respectively; p = 0.054). In multivariable analysis, factors associated with readmission included having EVAR during the index stay (Odds ratio [OR] = 1.46, 95% confidence interval [CI] 1.14-1.88; p = .003), increased length of index stay (OR = 1.01; 95% CI 1.01-1.02; p = 0.002), chronic kidney disease (OR = 1.51; 95% CI 1.18-1.94; p = .001), and coronary artery disease (OR = 1.32; 95% CI 1.02-1.71; p = .034). Aggregate readmission charges totaled $79 million. Readmissions were most often infectious complications for both repair types. CONCLUSIONS EVAR was used more often than open repair for rAAA. In-hospital mortality and length of the index stay were significantly lower following EVAR. After multivariable adjustment, the odds of readmission were 1.5 times higher after EVAR, costing the health system more over time when prevalence and readmission are considered. Coronary artery disease, chronic kidney disease, and index length of stay were also associated with 30-day readmission. Further investigation into reasons why a less invasive procedure, EVAR, has a higher readmission rate and understanding post-discharge infectious complications may help lower overall health care utilization after rAAA.
Collapse
Affiliation(s)
- Drew J Braet
- Division of Vascular Surgery, Department of Surgery, 2628University of Missouri, School of Medicine, Columbia, MO, USA
| | - John P Taaffe
- Division of Vascular Surgery, Department of Surgery, 2628University of Missouri, School of Medicine, Columbia, MO, USA
| | - Priyanka Singh
- Division of Vascular Surgery, Department of Surgery, 2628University of Missouri, School of Medicine, Columbia, MO, USA
| | - Jonathan Bath
- Division of Vascular Surgery, Department of Surgery, 2628University of Missouri, School of Medicine, Columbia, MO, USA
| | - Robin L Kruse
- Department of Family and Community Medicine, 2628University of Missouri, School of Medicine, Columbia, MO, USA
| | - Todd R Vogel
- Division of Vascular Surgery, Department of Surgery, 2628University of Missouri, School of Medicine, Columbia, MO, USA
| |
Collapse
|
8
|
Editor's Choice – Short Term and Long Term Outcomes After Endovascular or Open Repair for Ruptured Infrarenal Abdominal Aortic Aneurysms in the Vascular Quality Initiative. Eur J Vasc Endovasc Surg 2020; 59:703-716. [DOI: 10.1016/j.ejvs.2019.12.032] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Revised: 11/20/2019] [Accepted: 12/16/2019] [Indexed: 11/22/2022]
|
9
|
ANARCYL SCALE (ANeurisma de Aorta Roto Castilla y León) FOR PREDICTING MORTALITY IN RUPTURED ABDOMINAL AORTIC ANEURYSMS. ANGIOLOGIA 2020. [DOI: 10.20960/angiologia.00087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
|
10
|
Purkiss S, Keegel T, Vally H, Wollersheim D. Long-term survival following successful abdominal aortic aneurysm repair evaluated using Australian administrative data. ANZ J Surg 2019; 90:339-344. [PMID: 31828928 DOI: 10.1111/ans.15598] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 09/30/2019] [Accepted: 11/10/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Long-term survival (LTS) following abdominal aortic aneurysm (AAA) surgery is an outcome that can compare open surgical repair (OSR) and endovascular AAA repair (EVAR) methods. We examined the LTS of persons following successful AAA repair using administrative health data covering the Australian Pharmaceutical Benefits and Medicare Benefits Schemes from 1993 to 2014. METHODS Participants undergoing AAA surgery were identified using procedure codes and the last service provision date used as a proxy mortality marker. LTS and relative survival with control populations in those who survived the initial post-operative period were used to compare OSR and EVAR and estimates between the first and second halves of the study. RESULTS A total of 2060 persons who had undergone AAA repair were identified. Overall median LTS (95% CI) following elective, ruptured OSR and EVAR were 10.4 (9.1-11.0), 8.5 (6.7-10.3) and 9.7 (8.1-11.3) years, respectively. Relative survival rates at 5 and 10 years were 0.89 and 0.7 for OSR and 0.87 and 0.66 for EVAR. LTS rates were similar for OSR and EVAR in age groups 65-84 years (EVAR/OSR range 0.96-1.16); however, EVAR was superior to OSR in persons aged >85 years at 5 years (EVAR/OSR 1.32, log-rank P < 0.05). Relative survival following all techniques of AAA repair showed no significant change over the duration of the study. CONCLUSION LTS following AAA repair was heterogeneous in comparison with control populations and varied with age and procedure. The 5-year LTS following EVAR in persons aged >85 years is superior to OSR. Administrative data can define long-term outcomes following aortic aneurysm surgery and may complement data already collected by surgeons.
Collapse
Affiliation(s)
- Shaun Purkiss
- Department of Public Health, La Trobe University, Melbourne, Victoria, Australia
| | - Tessa Keegel
- Department of Public Health, La Trobe University, Melbourne, Victoria, Australia.,Monash Centre for Occupational and Environmental Health, Monash University, Melbourne, Victoria, Australia
| | - Hassan Vally
- Department of Public Health, La Trobe University, Melbourne, Victoria, Australia
| | - Dennis Wollersheim
- Department of Public Health, La Trobe University, Melbourne, Victoria, Australia
| |
Collapse
|