Incidence and outcomes of ruptured abdominal aortic aneurysms in rural and urban Australia

Survival following abdominal aortic aneurysm repair in North Queensland is not associated with remoteness of place of residence

Objective

To assess whether survival and clinical events following elective abdominal aortic aneurysm (AAA) repair were associated with remoteness of residence in North Queensland, Australia.

Methods

This retrospective cohort study included participants undergoing elective AAA repair between February 2002 and April 2020 at two hospitals in Townsville, North Queensland, Australia. Outcomes were all-cause survival and AAA-related events, defined as requirement for repeat AAA repair or AAA-related mortality. Remoteness of participant’s place of residence was assessed by the Modified Monash Model classifications and estimated distance from the participants’ home to the tertiary vascular centre. Cox proportional hazard analysis examined the association of remoteness with outcome.

Results

The study included 526 participants undergoing elective repair by open (n = 204) or endovascular (n = 322) surgery. Fifty-four (10.2%) participants had a place of residence at a remote or very remote location. Participants' were followed for a median of 5.2 (inter-quartile range 2.5–8.3) years, during which time there were 252 (47.9%) deaths. Survival was not associated with either measure of remoteness. Fifty (9.5%) participants had at least one AAA-related event, including 30 (5.7%) that underwent at least one repeat AAA surgery and 23 (4.4%) that had AAA-related mortality. AAA-related events were more common in participants resident in the most remote areas (adjusted hazard ratio 2.83, 95% confidence intervals 1.40, 5.70) but not associated with distance from the participants’ residence to the tertiary vascular centre

Conclusions

The current study found that participants living in more remote locations were more likely to have AAA-related events but had no increased mortality following AAA surgery. The findings emphasize the need for careful follow-up after AAA surgery. Further studies are needed to examine the generalisability of the findings.

Hospital admission volume does not impact the in-hospital mortality of acute pancreatitis

BACKGROUND

Multiple factors influence mortality in Acute Pancreatitis (AP).

METHODS

To evaluate the association of demographic, clinical, and hospital factors with the in-hospital mortality of AP using a population-based administrative database. The Maryland HSCRC database was queried for adult (≥18 years) admissions with primary diagnosis of AP between 1/94-12/10. Organ failure (OF), interventions, hospital characteristics and referral status were evaluated.

RESULTS

There were 72,601 AP admissions across 48 hospitals in Maryland with 885 (1.2%) deaths. A total of 1657 (2.3%) were transfer patients, of whom 101 (6.1%) died. Multisystem OF was present in 1078 (1.5%), of whom 306 (28.4%) died. On univariable analysis, age, male gender, transfer status, comorbidity, OF, all interventions, and all hospital characteristics were significantly associated with mortality; however, only age, transfer status, OF, interventions, and large hospital size were significant in the adjusted analysis. Patients with commercial health insurance had significantly less mortality than those with other forms of insurance (OR 0.65, 95% CI: 0.52, 0.82, p = 0.0002).

CONCLUSION

OF is the strongest predictor of mortality in AP after adjusting for demographic, clinical, and hospital characteristics. Admission to HV or teaching hospital has no survival benefit in AP after adjusting for OF and transfer status.

Perceived barriers to endovascular repair of ruptured abdominal aortic aneurysm among Australasian vascular surgeons

OBJECTIVE

Although endovascular abdominal aortic aneurysm (AAA) repair (EVAR) is widely accepted for elective surgery, the uptake of emergency EVAR for ruptured AAA (REVAR) has trailed behind. This study was intended to identify the barriers to widespread application of REVAR in Australia and New Zealand.

METHODS

A cross-sectional survey of members of the Australia and New Zealand Society of Vascular Surgeons was performed in late 2013. Primary themes explored were (1) perceived barriers to performing REVAR and (2) advantages of REVAR compared with open repair. Secondary data measures were the volume of AAA surgery, standard protocol use, and staff accreditation among vascular units.

RESULTS

A total of 85 surgeons responded to an anonymous online questionnaire (41% response rate); of these, 23 surgeons (27%) had no experience with REVAR, and 65% currently perform more EVAR than open repair for elective procedures, compared with 18% for ruptured AAA. Of the perceived barriers explored, respondents agreed that poor availability of endovascular facilities (73% agreed or strongly agreed) and ancillary staff (56%) were barriers to REVAR. Most surgeons agreed that the advantages of REVAR include reduced intraoperative blood loss, length of stay, and postoperative complications. Four of 11 vascular units performing REVAR had standard protocols in use, and four had mandatory staff accreditation.

CONCLUSIONS

The most common barrier to REVAR identified by surgeons was the poor availability of endovascular facilities, many of which are not ideally suited for this type of procedure. Australian and New Zealand vascular units have low rates of standard protocol use and staff accreditation for REVAR, which may have implications for patient care.

Mortality outcomes of ruptured abdominal aortic aneurysms and rural presentation

OBJECTIVES

Centralisation of vascular surgery services has coincided with a move towards endovascular repair of ruptured abdominal aortic aneurysms with the goal to improve patient outcomes. The aim of this study was to assess the effect of rural presentation and transfer times on survival from ruptured abdominal aortic aneurysm.

DESIGN

A retrospective review.

MATERIALS

All patients presenting with ruptured abdominal aortic aneurysm to public hospitals in Tasmania between July 2006 and April 2013.

METHODS

Demographic data, Glasgow aneurysm score, Hardman index, transfer times, operative technique and 30-day mortality were collected from medical records.

RESULTS

Over the study period 127 patients presented to public hospitals in Tasmania with ruptured abdominal aortic aneurysm. A total of 27 presented to north west hospitals where no vascular surgery service is provided (NWRH), 23 to a northern hospital where an intermittent vascular surgery service is provided (LGH) and 77 to the state tertiary vascular surgery service (RHH). Of these, 4 (14.8%) died at NWRH, 6 (26.1%) died at LGH and 43 (55.8%) died at RHH without operation. Of the 35 patients transferred from NWRH and LGH to RHH, 5 died without operation. Median time from presentation to theatre at RHH if transferred from NWRH was 6.25 hours, from the LGH 4.75 hours, compared to 2.75 hours when presenting directly to RHH. Open repair was performed in 41 patients and endovascular repair in 23 patients. Overall 30-day mortality in those treated at RHH was 26.6% (39.0% for open repair, 4.3% for endovascular repair). Mortality for intended operative patients initially presenting to non-RHH hospitals was 33.3% vs. 32.3% for those initially presenting to RHH. p Value 0.93.

CONCLUSION

There was no clinical or statistical disadvantage to rural presentation and transfer for patients presenting with ruptured abdominal aortic aneurysm in Tasmania. Endovascular repair has a role despite long transfer times.