Should usual criteria for intervention in abdominal aortic aneurysms be "downsized," considering reported risk reduction with endovascular repair?

National trends and regional variation of open and endovascular repair of thoracic and thoracoabdominal aneurysms in contemporary practice

OBJECTIVES

Successful surgical management of thoracic aortic aneurysms (TAA) and thoracoabdominal aortic aneurysms (TAAA) has historically relied upon open surgical repair (OSR). More recently, the advent and application of thoracic endovascular stent graft aneurysm repair (TEVAR) permutations have become increasingly performed in contemporary practice. To better determine the effect of TEVAR techniques on OSR, we examined national and regional trends in treatment use.

METHODS

All Medicare patients from 1998 through 2007 undergoing isolated TAA and TAAA repair were analyzed using a clinically validated algorithm using diagnostic International Classification of Disease 9th revision (ICD-9; 441.1, 441.2, 441.6, 441.7, 441.9) codes and procedural (ICD-9 OSR: 38.35, 38.45 and TEVAR: 39.73, 39.79) codes. Differential rates of OSR and TEVAR were compared across census tract regions during the study interval.

RESULTS

Total complex aortic repairs increased by 60%, from 10.8 to 17.8/100,000, between 1998 and 2007 (P < .001). A dramatic increase occurred in TEVAR (not performed in 1998, 5.8/100,000 in 2007) during the study period, but OSR rates remained stable during the same interval (10.7 to 12.0/100,000 in 2007, P = NS). There was substantial regional variation for both OSR and TEVAR. This regional variation was greater in OSR (range, 8.8-16.7/100,000) than in TEVAR (range, 4.5-6.9/100,000).

CONCLUSIONS

Degenerative TAA and TAAA aneurysms are being repaired in the United States at an increasing rate. This reflects the rapid acceptance of TEVAR, which apparently supplements rather than supplants OSR. There appears to be greater regional variation in OSR compared with TEVAR. These data may have significant implications for those interested in the effect of new technologies on health care and cost containment.

Thirty-day mortality and late survival with reinterventions and readmissions after open and endovascular aortic aneurysm repair in Medicare beneficiaries

OBJECTIVES

Late survival is similar after open and endovascular abdominal aortic aneurysm (AAA) repair (EVAR), despite a perioperative benefit with EVAR. AAA-related reinterventions are more common after EVAR, whereas laparotomy-related reinterventions are more common after open repair. The effect of reinterventions on survival, however, is unknown. We therefore evaluated the rate of reinterventions and readmission after initial AAA repair, 30-day mortality, and the effect on long-term survival.

METHODS

We identified AAA-related and laparotomy-related reinterventions for propensity score-matched cohorts of 45,652 Medicare beneficiaries undergoing EVAR and open repair from 2001 to 2004. Follow-up was up to 6 years. Hospitalizations for ruptured AAA without repair and for bowel obstruction or ventral hernia without abdominal surgery were also recorded. Event rates were calculated per year and are presented through 6 years of follow-up as events per 100 person-years. Thirty-day mortality was calculated for each reintervention or readmission.

RESULTS

Through 6 years, overall reinterventions or readmissions were similar between repair methods but slightly more common after EVAR (7.6 vs 7.0/100 person-years; relative risk [RR], 1.1; P < .001). Overall 30-day mortality with any reintervention or readmission was 9.1%. EVAR patients had more ruptures (0.50 vs 0.09 [RR, 5.7; P < .001]), with a mortality of 28%, but these were uncommon. EVAR patients also had more AAA-related reinterventions through 6 years (3.7 vs 0.9 [RR, 4.0; P < .001]; mortality, 5.6%), most of which were minor endovascular reinterventions (2.4 vs 0.2 [RR, 11.4; P < .001]), with a 30-day mortality of 3.0%. However, minor open (0.8 vs 0.5 [RR, 1.4; P < .001]; mortality, 6.9%) and major reinterventions (0.4 vs 0.2 [RR, 2.4; P < .001]; mortality, 12.1%) were also more common after EVAR than open repair. Conversely, EVAR patients had fewer laparotomy-related reinterventions than open patients (1.4 vs 3.0 [RR, 0.5; P < .001]; mortality, 8.1%) and readmissions without surgery (2.0 vs 2.7 [RR, 0.7; P < .001]; mortality 10.9%). Overall, reinterventions or readmission accounted for 9.6% of all EVAR deaths and 7.6% of all open repair deaths in the follow-up period (P < .001).

CONCLUSIONS

Reintervention and readmission are slightly higher after EVAR. Survival is negatively affected by reintervention or readmission after EVAR and open surgery, which likely contributes to the erosion of the survival benefit of EVAR over time.

Parathyroidectomy is safe and improves symptoms in elderly patients with primary hyperparathyroidism (PHPT)

OBJECTIVE

Parathyroidectomy for primary hyperparathyroidism (PHPT) is curative in over 95% of cases. Although PHPT affects up to 2% of the elderly population, whose life expectancy may be a decade or more, such patients may be denied surgery because of perceived risk. This study investigates the outcomes of surgery for PHPT in the elderly.

DESIGN AND PATIENTS

Consecutive patients with PHPT treated at a tertiary referral centre over 5 years.

MEASUREMENTS

A prospective database recorded clinical, biochemical and pathological information. Pasieka's parathyroid symptom scores were obtained pre-operatively and post-operatively, from a recent subgroup of 70 consecutive patients. Deaths during follow-up were identified using the NHS Strategic Tracing Service. Statistical analysis was performed with spss v12.0.

RESULTS

Between November 2002 and October 2007, 224 patients (17-89 years) underwent surgery for PHPT. In the subgroup comprising patients aged >75 years there was a significantly greater proportion of women (47/56 vs. 52/81, P < 0.05). Pre-operative indices of these patients were similar to younger patients, as were proportions undergoing minimally invasive parathyroidectomy (n = 134) or bilateral neck exploration (n = 90). Patients >75 years had a longer hospital stay (1.6 vs. 0.8 days, P = 0.003). Pasieka's symptom scores improved significantly at 3-6 months postoperatively in all age groups. During a minimum median follow-up of 22 months, there were seven patients with persistent/recurrent disease. Median 2-year survival of those aged 60-74 and those over 75 ranged from 85-90%.

CONCLUSION

Parathyroidectomy is safe in the elderly and is associated with a significant improvement in symptoms. As survival after operation is similar to younger patients, surgery should be considered in all elderly patients with PHPT.