Health-Related Quality of Life Outcomes Following Elective Open or Endovascular AAA Repair:A Randomized Controlled Trial

Quantifying the burden of survivorship associated with infrarenal abdominal aortic aneurysms

OBJECTIVES

Survivorship encompasses the physical, psychological, social, functional, and economic experience of a living with a chronic condition for both the patient and their caregiver. It is made up of nine distinct domains and remains understudied in nononcological pathologies, including infrarenal abdominal aortic aneurysmal disease (AAA). This review aims to quantify the extent to which existing AAA literature addresses the burden of survivorship.

METHODS

The MEDLINE, EMBASE, and PsychINFO databases were searched from 1989 through September 2022. Randomized controlled trials, observational studies, and case series were included. Eligible studies had to detail outcomes related to survivorship in patients with AAA. Owing to the heterogeneity between studies and outcomes, no meta-analysis was conducted. Study quality was assessed with specific risk of bias tools.

RESULTS

A total of 158 studies were included. Of these, only five (treatment complications, physical functioning, comorbidities, caregivers, and mental health) of the nine domains of survivorship have been studied previously. The available evidence is of variable quality; most studies display a moderate to high risk of bias, are of an observational study design, are based within a limited number of countries, and consist of an insufficient follow-up period. The most frequent complication after EVAR was endoleak. EVAR is associated with poorer long-term outcomes compared with open surgical repair in most studies retrieved. EVAR showed better outcomes in regard to physical functioning in the short term, but this advantage was lost in the long term. The most common comorbidity studied was obesity. No significant differences were found between open surgical repair and EVAR in terms of impact on caregivers. Depression is associated with various comorbidities and increased the risk of a nonhospital discharge.

CONCLUSIONS

This review highlights the absence of robust evidence regarding survivorship in AAA. As a result, contemporary treatment guidelines rely on historic quality-of-life data that are narrow in scope and nonrepresentative of contemporary clinical practice. As such, there is an urgent need to reevaluate the aims and methodology associated with traditional quality-of-life research moving forward.

Quality of Life of Patients Treated for Abdominal Aortic Aneurysm: Open Surgery and Endoprosthesis

Objectives: To determine the degree of long-term health-related quality of life (HRQoL) of patients undergoing surgery for abdominal aortic aneurysm (AAA) and to analyze the results according to the type of treatment, namely, open abdominal repair (OAR) or endoprosthesis (EVAR). Patients and Methods: This was a prospective cross-sectional observational study. Patients receiving intervention for AAA between January 2013 and December 2020 were included. The Spanish version of the SF-36 questionnaire was used. A single survey was performed on all patients, and the time elapsed since the intervention was recorded. Results: On all health scales and in the two groups of patients, the highest scores were recorded at six months postoperatively. At that time, the EVAR and OAR groups had similar values. Between 13 and 16 months postoperatively, EVAR patients presented a transient but significant decrease in their scores for physical function (p = 0.016), vitality (p = 0.035) and social function (p = 0.041). From that moment, there were progressive decreases in the scores of the two groups of patients on all the scales of the SF-36 questionnaire, although this trend was less pronounced in the OAR group. At 60 months after the intervention, the latter group showed significantly higher values than EVAR for physical function (p = 0.01), vitality (p = 0.032) and mental health (p = 0.029). Additionally, at 60 months after the intervention, the Sum of the psychological component (MCS) and Sum of the physical component (PCS) scores were significantly higher in the OAR group (p = 0.040 and p = 0.039, respectively). Conclusions: In the short term, patients treated for AAA by EVAR or OAR showed similar results on the SF-36 questionnaire. In the long term, patients treated by EVAR had lower scores on the physical function, vitality and mental health scales.

ANALYSIS OF SPIN IN VASCULAR SURGERY RANDOMIZED CONTROLLED TRIALS WITH NONSIGNIFICANT OUTCOMES

OBJECTIVES

Spin is the manipulation of language that distorts the interpretation of objective findings. The purpose of this study is to describe the characteristics of spin found in statistically nonsignificant randomized controlled trials (RCT) comparing carotid endarterectomy (CEA) to carotid artery stenting (CAS) for carotid stenosis (CS), and endovascular repair (EVAR) to open repair (OR) for abdominal aortic aneurysms (AAA).

METHODS

A search of MEDLINE, EMBASE, and the Cochrane Controlled Register of Trials was performed in June 2020 for studies published describing AAA or CS. All phase three RCTs with nonsignificant primary outcomes comparing OR to EVAR or CEA to CAS were included. Studies were appraised for the characteristics and severity of spin using a validated tool. Binary logistic regression was performed to assess the association of spin grade to (1) funding source (commercial vs non-commercial) and (2) the publishing journal's impact factor.

RESULTS

Thirty-one of 355 articles captured were included for analysis. Spin was identified in nine abstracts (9/18) and 13 main texts (13/18) of AAA articles and seven abstracts (7/13) and ten main texts (10/13) of CS articles. For both AAA and CS articles, spin was most commonly found in the manuscript discussion section, with the most commonly employed strategy being the interpretation of statistically nonsignificant primary results to show treatment equivalence or rule out adverse treatment effects. Increasing journal impact factor was associated with a statistically significant lower likelihood of spin in the study title or abstract conclusion (βOR = 0.96, 95% CI: 0.94 - 0.98, p < 0.01) while no significant association could be found with funding source (βOR = 1.33, 95% CI: 0.30-5.92, p = 0.71).

CONCLUSIONS

A large proportion of statistically nonsignificant RCTs contain interpretations that are inconsistent with their results. These findings should prompt authors and readers to appraise study findings independently and to limit the use of spin in study interpretations.

Towards Patient Centred Outcomes for Elective Abdominal Aortic Aneurysm Repair: A Scoping Review of Quality of Life Scales

OBJECTIVE

In order to better incorporate the patient's perspective in medical decision making, core outcome sets (COS) are being defined. In the field of abdominal aortic aneurysm (AAA), efforts to capture the patient's perspective focus on generic quantitative quality of life (QoL) scales. The question arises whether these quantitative scales adequately reflect the patient's perspective on QoL, and whether they can be included in the QoL aspect of COS. A scoping review of QoL assessment in the context of elective AAA repair was undertaken.

DATA SOURCES

PubMed, Embase, Web of Science, and the Cochrane Library.

REVIEW METHODS

A scoping review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines. Articles reporting QoL assessment in the context of elective AAA repair were identified. Quantitative studies (i.e., traditional QoL scales) were aligned (triangulation approach) with qualitative studies (i.e., patient perspective) to identify parallels and discrepancies. Mean Short Form 36 item survey (SF-36) scores were pooled using a random effects model to evaluate sensitivity to change.

RESULTS

Thirty-three studies were identified, of which 29 (88%) were quantitative and four (12%) qualitative. The 33 studies reported a total of 54 quantitative QoL scales; the most frequently used were the generic SF-36 (16 studies) and five dimension EuroQol (EQ-5D; eight studies). Aneurysm specific scales were reported by one study. The generic quantitative scales showed poor alignment with the patient's perspective. The aneurysm specific scales better aligned but missed "concerns regarding symptoms" and "the impact of possible outcomes/complications". "Self control and decision making", which was brought forward by patients in qualitative studies, was not captured in any of the current scales.

CONCLUSION

There is no established tool that fully captures all aspects of the patient's perspective appropriate for a COS for elective AAA repair. In order to fulfil the need for a COS for the management of^, AAA disease, a more comprehensive overview of the patient's perspective is required.

Clinical outcomes and quality of life in patients with acute and subacute type B aortic dissection after thoracic endovascular aortic repair

Objective

Thoracic endovascular aortic repair (TEVAR) is considered the mini-invasive treatment of choice for patients with Stanford type B aortic dissection (TBAD). This study aimed to investigate the clinical outcomes and quality of life (QoL) in patients with acute and subacute TBAD after TEVAR.

Methods

From January 2014 until July 2016, 22 acute patients (Group A) and 18 subacute patients received TEVAR (Group B), and 13 patients were managed non-operatively (Group C). The Medical Outcomes Study Short Form-36 was used to assess QoL preoperatively and after TEVAR. Operative techniques and complications were retrospectively analyzed.

Results

The role emotion, vitality, and mental health domains scored well preoperatively. Except for role emotion, vitality, and mental health, the remaining domains significantly improved after TEVAR. There was no significant difference in QoL metrics between Groups A and B. In Group C, bodily pain and social functioning domains were improved, and role emotion was decreased, with no improvement in the remaining domains. The 3-year survival rates were 95.5%, 100%, and 85.7% for Groups A, B, and C, respectively.

Conclusions

TEVAR may be safe and effective in patients with acute and subacute TBAD with similar and favorable clinical and QoL metrics.

Editor's Choice - Endovascular vs. Open Repair for Abdominal Aortic Aneurysm: Systematic Review and Meta-analysis of Updated Peri-operative and Long Term Data of Randomised Controlled Trials

OBJECTIVE

The objective was to investigate whether endovascular aneurysm repair (EVAR) has better peri-operative and late clinical outcomes than open repair for non-ruptured abdominal aortic aneurysm.

METHODS

Electronic bibliographic sources (MEDLINE, EMBASE, and CENTRAL) were searched up to July 2019 using a combination of thesaurus and free text terms to identify randomised controlled trials (RCTs) comparing the outcomes of EVAR and open repair. The systematic review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Pooled estimates of dichotomous outcomes were calculated using odds ratio (OR) or risk difference (RD) and 95% confidence interval (CI). A time to event data meta-analysis was performed using the inverse variance method and the results were reported as summary hazard ratio (HR) and 95% CI.

RESULTS

Seven RCTs reporting a total of 2 983 patients were included in quantitative synthesis. Three of the trials reported long term follow up that extended to 15.8 years, 14.2 years, and 12.5 years. Meta-analysis found significantly lower odds of 30 day (OR, 0.36; 95% CI 0.20-0.66) and in hospital mortality with EVAR (RD -0.03; 95% CI -0.04 to -0.02). Meta-analysis of the three trials reporting long term follow up found no significant difference in all cause mortality at any time between EVAR and open repair (HR 1.02; 95% CI 0.93-1.13; p = .62). The hazard of all cause (HR 0.62; 95% CI 0.42-0.91) and aneurysm related death within six months (HR 0.42; 95% CI 0.24-0.75) was significantly lower in patients who underwent EVAR, but with further follow up, the pooled hazard estimate moved in favour of open surgery; in the long term (>8 years) the hazard of aneurysm related mortality was significantly higher after EVAR (HR 5.12; 95% CI 1.59-16.44). The risk of secondary intervention (HR 2.13; 95% CI 1.69-2.68), aneurysm rupture (OR, 5.08; 95% CI 1.11-23.31), and death due to rupture (OR, 3.57; 95% CI 1.87-6.80) was significantly higher after EVAR, but the risk of death due to cancer was not significantly different between EVAR and open repair (OR, 1.03; 95% CI 0.84-1.25).

CONCLUSION

Compared with open surgery, EVAR results in a better outcome during the first six months but carries an increased risk of aneurysm related mortality after eight years.

Life is about so much more: Patients' experiences of health, well-being, and recovery after operation of abdominal aortic aneurysm with open and endovascular treatment-A prospective study

Different surgical treatments for abdominal aortic aneurysm can lead to different perceptions of health and well-being. The aim of this study was to describe patients' well-being, sense of coherence (SOC), and experiences of surgery after open and endovascular treatment one month and one and 2 years after the procedure. Seventy six patients participated (40 open repair; 36 endovascular aneurysm repair). The study was conducted using the SOC questionnaire, and specific questions about patients' experiences of the surgical treatment and well-being. After 2 years, no patient regretted the operation or considered it to be the most difficult experience they had ever had. Twenty percent of the patients were worried about complications one month after the operation. Both groups experienced difficulty in returning to normal activity after surgery at one month. At one and 2 years after the surgery, patients in both groups stated that it was other things in life that affected their well-being. The endovascular aneurysm repair group reported a significant decrease in SOC from baseline until one year (P = .012) and 2 years (P = .033). The open repair group reported a significant decrease after one year (0.033). The operation did not affect patients' way of thinking about the disease. Patients in both groups stated that it was other circumstances in life that affected their well-being one and 2 years after the treatment, which could indicate that long-term follow-up would not be necessary from a patient perspective. The operation affects patients' well-being a short time after the operation.

Prospective assessment of health-related quality of life after endovascular repair of pararenal and thoracoabdominal aortic aneurysms using fenestrated-branched endografts

OBJECTIVE

The objective of this study was to investigate changes in health-related quality of life (QOL) in patients treated for pararenal aortic aneurysms (PAAs) and thoracoabdominal aortic aneurysms (TAAAs) with fenestrated-branched endovascular aneurysm repair (F-BEVAR).

METHODS

A total of 159 consecutive patients (70% male; mean age, 75 ± 7 years) were enrolled in a prospective, nonrandomized single-center study using manufactured F-BEVAR (2013-2016). All patients were observed for at least 12 months (mean follow-up time, 27 ± 12 months). Patients' health-related QOL was assessed using the 36-Item Short Form Health Survey questionnaire at baseline (N = 159), 6 to 8 weeks (n = 136), 6 months (n = 129), and 12 months (n = 123). Physical component scores (PCSs) and mental component scores (MCSs) were compared with historical results of patients enrolled in the endovascular aneurysm repair (EVAR) 1 trial who were treated by standard EVAR for simple infrarenal abdominal aortic aneurysms.

RESULTS

There were 57 patients with PAAs and 102 patients with TAAAs (50 extent IV and 52 extent I-III TAAAs). There were no 30-day deaths, in-hospital deaths, conversions to open surgery, or aorta-related deaths. Survival was 96% at 1 year and 87% at 2 years. Major adverse events occurred in 18% of patients, and 1-year reintervention rate was 14%. There were no statistically significant differences between the groups in 30-day outcomes. Patients treated for TAAAs had lower baseline scores compared with those treated for PAAs (P < .05). PCS declined significantly 6 to 8 weeks after F-BEVAR in both groups and returned to baseline values at 12 months in the PAA group but not in the TAAA group. Patients with TAAAs had significantly lower PCSs at 12 months compared with those with PAAs (P < .001). There was no decline in mean MCS. Major adverse events were associated with decline in PCS assessed at 6 to 8 weeks (P = .021) but not in the subsequent evaluations. Reinterventions had no effect on PCS or MCS. Overall, patients treated by F-BEVAR had similar changes in QOL measures as those who underwent standard EVAR in the EVAR 1 trial, except for lower PCS in TAAA patients at 12 months.

CONCLUSIONS

Patients treated for TAAAs had lower scores at baseline in their physical aspect of health-related QOL. F-BEVAR was associated with significant decline in PCSs in both groups, which improved after 2 months and returned to baseline values at 12 months in patients with PAAs but not in those with TAAAs. Patients treated for PAAs had similar changes in QOL compared with those treated for infrarenal aortic aneurysms with standard EVAR.

Quality of life from a randomized trial of open and endovascular repair for abdominal aortic aneurysm

Background

Long-term survival is similar after open or endovascular repair of abdominal aortic aneurysm. Few data exist on the effect of either procedure on long-term health-related quality of life (HRQoL) and health status.

Methods

Patients enrolled in a multicentre randomized clinical trial (DREAM trial; 2000–2003) in Europe of open repair versus endovascular repair (EVAR) of abdominal aortic aneurysm were asked to complete questionnaires on health status and HRQoL. HRQoL scores were assessed at baseline and at 13 time points thereafter, using generic tools, the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36®) and EuroQol 5D (EQ-5D™). Physical (PCS) and mental component summary scores were also calculated. Follow-up was 5 years.

Results

Some 332 of 351 patients enrolled in the trial returned questionnaires. More than 70 per cent of questionnaires were returned at each time point. Both surgical interventions had a short-term negative effect on HRQoL and health status. This was less severe in the EVAR group than in the open repair group. In the longer term the physical domains of SF-36® favoured open repair: mean difference in PCS score between open repair and EVAR −1·98 (95 per cent c.i. −3·56 to −0·41). EQ-5D™ descriptive and EQ-5D™ visual analogue scale scores for open repair were also superior to those for EVAR after the initial 6-week interval: mean difference −0·06 (−0·10 to −0·02) and −4·09 (−6·91 to −1·27) respectively.

Conclusion

In this study EVAR appeared to be associated with less severe disruption to HRQoL and health status in the short term. However, during longer-term follow-up to 5 years, patients receiving open repair appeared to have improved quality of life and health status.

Enhanced recovery after elective open surgical repair of abdominal aortic aneurysm: a complementary overview through a pooled analysis of proportions from case series studies

OBJECTIVES

To evaluate the efficacy and safety of enhanced recovery after surgery (ERAS) programs in elective open surgical repair (OSR) of abdominal aortic aneurysm (AAA).

BACKGROUND

Open surgical repair of AAA is associated with high morbidity and mortality, prolonged hospital stay and high costs. ERAS programs contribute to the optimization of treatment by reducing hospital stay and improving clinical outcomes.

METHODS

A review of PubMed, EMBASE and LILACS databases was conducted. As only one randomized controlled trial was found, a pooled analysis of proportions from case series was conducted, considering it a complementary overview of the topic. Inclusion criteria were case series with more than five cases reported, adult patients who underwent an elective OSR of AAA and use of an ERAS program. ERAS was compared to conventional perioperative care. The pooled proportion and the confidence interval (CI) are shown for each outcome. The overlap of the CI suggests similar effect of the interventions studied.

RESULTS

Thirteen case series studies with ERAS involving 1,250 patients were compared to six case series with conventional care with a total of 1,429 patients. The pooled, respective proportions for ERAS and conventional care were: mortality, 1.51% [95% CI: 0.0091, 0.0226] and 3.0% [95% CI 0.0183, 0.0445]; and incidence of complications, 3.82% [95% CI 0.0259, 0.0528] and 4.0% [95% CI 0.03, 0.05].

CONCLUSION

This review shows that ERAS and conventional care therapies have similar mortality and complication rates in OSR of AAA.

Endovascular repair of abdominal aortic aneurysm

BACKGROUND

An abnormal dilatation of the abdominal aorta is referred to as an abdominal aortic aneurysm (AAA). Due to the risk of rupture, surgical repair is offered electively to individuals with aneurysms greater than 5.5 cm in size. Traditionally, conventional open surgical repair (OSR) was considered the first choice approach. However, over the past two decades endovascular aneurysm repair (EVAR) has gained popularity as a treatment option. This article intends to review the role of EVAR in the management of elective AAA.

OBJECTIVES

To assess the effectiveness of EVAR versus conventional OSR in individuals with AAA considered fit for surgery, and EVAR versus best medical care in those considered unfit for surgery. This was determined by the effect on short, intermediate and long-term mortality, endograft related complications, re-intervention rates and major complications.

SEARCH METHODS

The Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator (TSC) searched the Specialised Register (January 2013) and the Cochrane Central Register of Controlled Trials (CENTRAL) (2012, Issue 12). The TSC also searched trial databases for details of ongoing or unpublished studies.

SELECTION CRITERIA

Prospective randomised controlled trials (RCTs) comparing EVAR with OSR in individuals with AAA considered fit for surgery. and comparing EVAR with best medical care in individuals considered unfit for surgery. We excluded studies with inadequate data or using an inadequate randomisation technique.

DATA COLLECTION AND ANALYSIS

Three reviewers independently evaluated trials for appropriateness for inclusion and extracted data using pro forma designed by the Cochrane PVD Group. We assessed the quality of trials using The Cochrane Collaboration's 'Risk of bias' tool. We entered collected data in to Review Manager (version 5.2.3) for analysis. Where direct comparisons could be made, we determined odds ratios (OR). We tested studies for heterogeneity and, when present, we used a random-effects model; otherwise we used a fixed-effect model. We tabulated data that could not be collated.

MAIN RESULTS

Four high-quality trials comparing EVAR with OSR (n = 2790) and one high-quality trial comparing EVAR with no intervention (n = 404) fulfilled the inclusion criteria. In individuals considered fit for surgery, a pooled analysis, including 1362 individuals randomised to EVAR and 1361 randomised to OSR, found short-term mortality (including 30-day or inhospital mortality, excluding deaths prior to intervention) with EVAR to be significantly lower than with OSR (1.4% versus 4.2%, OR 0.33, 95% confidence interval (CI) 0.20 to 0.55; P < 0.0001). Using intention-to-treat analysis (ITT) there was no significant difference in mortality at intermediate follow-up (up to four years from randomisation), with 221 (15.8%) and 237 (17%) deaths in the EVAR (n = 1393) and OSR (n = 1390) groups, respectively (OR 0.92, 95% CI 0.75 to 1.12; P = 0.40). There was also no significant difference in long-term mortality (beyond four years), with 464 (37.3%) deaths in the EVAR and 470 (37.8%) deaths in the OSR group (OR 0.98, 95% CI 0.83 to 1.15; P = 0.78). Similarly, there was no significant difference in aneurysm-related mortality between groups, either at the intermediate- or long-term follow up.Studies showed that both EVAR and OSR were associated with similar incidences of cardiac deaths (OR 1.14, 95% CI 0.86 to 1.52; P = 0.36) and fatal stroke rate (OR 0.81, 95% CI 0.42 to 1.55; P = 0.52). The long-term reintervention rate was significantly higher in the EVAR group than in the OSR group (OR 1.98, 95% CI 1.12 to 3.51; P = 0.02; I(2) = 85%). Results of the reintervention analysis should be interpreted with caution due to significant heterogeneity. Operative complications, health-related quality of life and sexual dysfunction were generally comparable between the EVAR and OSR groups. However, there was a slightly higher incidence of pulmonary complications in the OSR group compared with the EVAR group (OR 0.36, 95% CI 0.17 to 0.75; P = 0.006).In individuals considered unfit for conventional OSR, the one included trial found no difference between the EVAR and no-intervention groups with regard to all-cause mortality at final follow up, with 21.0 deaths per 100 person-years in the EVAR group and 22.1 deaths per 100 person years in the no-intervention group (adjusted hazard ratio (HR) with EVAR 0.99, 95% CI 0.78 to 1.27; P = 0.97). Aneurysm-related deaths were, however, significantly higher in the no-intervention group than in the EVAR group (adjusted HR 0.53, 95% CI 0.32 to 0.89; P = 0.02). There was no difference in myocardial events (HR 1.07, 95% CI 0.60 to 1.91) between the groups in this study.

AUTHORS' CONCLUSIONS

In individuals considered fit for conventional surgery, EVAR was associated with lower short-term mortality than OSR. However, this benefit from EVAR did not persist at the intermediate- and long-term follow ups. Individuals undergoing EVAR had a higher reintervention rate than those undergoing OSR. Most of the reinterventions undertaken following EVAR, however, were catheter-based interventions associated with low mortality. Operative complications, health-related quality of life and sexual dysfunction were generally comparable between EVAR and OSR. However, there was a slightly higher incidence of pulmonary complications in the OSR group than in the EVAR group.In individuals considered unfit for open surgery, the results of a single trial found no overall short- or long-term benefits of EVAR over no intervention with regard to all-cause mortality, but individuals may differ and individual preferences should always be taken into account.

Open Versus Endovascular Stent Graft Repair of Abdominal Aortic Aneurysms

We performed an analysis to assess the need for conducting additional randomized controlled trials (RCTs) comparing open and endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA). Trial sequential analysis (TSA) is a statistical methodology that can calculate the required information size of a meta-analysis and assess the risk of random errors similar to interim analysis in a single optimally powered trial. It helps to decide whether we have obtained sufficient evidence or whether further RCTs are required. For short-term mortality reintervention rates, TSA showed firm evidence that there would be no extra benefit in conducting more RCTs to detect the effectiveness of EVAR versus open repair. For long-term mortality, TSA revealed either inconclusive evidence to support or refute endovascular or open repair; so, further RCTs should be performed to investigate long-term, all-cause mortality after AAA repair.

Systematic review and meta-analysis of the early and late outcomes of open and endovascular repair of abdominal aortic aneurysm

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 &lt; 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 &lt; 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.

Construct domain analysis of patient health-related quality of life: physical and mental trajectory profiles following open versus endovascular repair of abdominal aortic aneurysm

Purpose

Many clinical trials comparing the outcomes of open surgical repair (OSR) versus endovascular aneurysm repair (EVAR) for abdominal aortic aneurysms (AAAs) have been conducted, with varying results. Surprisingly, few outcomes studies have closely examined perceived physical and mental health-related quality of life (HRQOL) factors through a validated survey tool. The purpose of this prospective observational study was to describe the trajectory of HRQOL measures, from baseline to 1 year after surgery, in patients undergoing OSR or EVAR for AAA, and to explore for differences in physical and mental composite scores and their construct domains (subscales) using the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36^®) tool.

Patients and methods

Over an 18-month period, a small sample of patients undergoing elective AAA repair in a community hospital setting were prospectively enrolled. Fifteen patients undergoing OSR and twenty patients undergoing EVAR were studied. Physical and mental HRQOL parameters were assessed using the SF-36.

Results

No significant differences in demographic and clinical variables were found between the OSR and EVAR groups. In the multivariable linear models with repeated measures, both groups showed a significant decline in physical health composite scores 30 days after the surgical procedure (P < 0.01). However, although the OSR group showed a statistically significant decline in three of the four physical health domains, the EVAR group declined in only one physical health domain. Only the OSR group showed a significant decline in three of the four mental health domains at 30 days; however, the decline of these domains was not reflected in the group’s mental health composite scores. By 90 days after surgery, both groups were not significantly different from their baseline in physical or mental health composite scores, or in any of their respective physical health domains.

Conclusion

In this small sample of patients undergoing AAA repair, EVAR resulted in less physical and emotional decline than OSR in the early postoperative period. However, patients in both groups may return to near baseline status at 90 days.

Meta-analysis of prospective trials determining the short- and mid-term effect of elective open and endovascular repair of abdominal aortic aneurysms on quality of life

Background

Repair of an abdominal aortic aneurysm (AAA) is undertaken to prevent rupture. Intervention is by either open repair (OR) or a more minimally invasive endovascular repair (EVAR). Quality-of-life (QoL) analysis is an important health outcome and a number of single studies have assessed QoL following OR and EVAR. This was a meta-analysis of published studies to assess the effect of an intervention on QoL in patients with an AAA.

Methods

A systematic literature search was undertaken for studies prospectively reporting QoL analysis in patients with an AAA undergoing elective intervention. A multivariable meta-analysis model was developed in which the outcomes were mean changes in QoL scores over time, both for all AAA repairs (OR and EVAR) and comparing OR with EVAR.

Results

Data were collated from 16 studies (14 OR, 12 EVAR). The results suggested that treating an AAA had an effect on patient-reported QoL, evident from the statistically significant changes predominantly in domains assessing physical ability and pain. QoL was affected most within the first 3 months after any form of intervention, and was more pronounced following OR. Furthermore, a deterioration in the Physical Component Summary score following an AAA repair (either OR or EVAR) was evident at 12 months after intervention.

Conclusion

Treating an AAA deleteriously affects patient-reported QoL over the first year following intervention.

Questions remain about quality of life after abdominal aortic aneurysm repair

INTRODUCTION

Morbidity and mortality have traditionally been used as key markers of surgical outcome. However, as complication rates associated with abdominal aortic aneurysm (AAA) repair decrease, subjective measures, such as quality of life (QOL), are increasingly recognized as important indicators of treatment efficacy and quality of care. This review presents the existing evidence relating to QOL changes in patients undergoing AAA repair by open repair (OR) and endovascular techniques (EVAR) and challenges current misconceptions about the relative effect of these two procedures.

METHODS

A comprehensive literature search was performed to identify studies relating to QOL or health status in AAA repair. Quality of included studies was assessed according to Scottish Intercollegiate Guidelines Network methodology.

RESULTS

Twenty-three studies satisfied the inclusion criteria. Preoperative QOL in AAA patients has been previously suggested as being worse than that of the general population, that OR patients have a worse QOL in the early postoperative period, and that EVAR patients have a worse QOL in the longer term. None of these assertions is uniformly supported in the literature. From the existing evidence, no clear conclusions can be drawn about the relative QOL benefits of OR vs EVAR.

CONCLUSIONS

There are a paucity of good-quality data relating to health status and QOL in patients undergoing AAA repair. Little is known about the prevalence of preoperative or postoperative symptoms and the degree to which these influence patient well-being. Further investigation is needed to clarify health status and QOL changes in these patients and allow clinicians to make targeted improvements in practice.

Risk factors for postoperative cognitive and functional difficulties in abdominal aortic aneurysm patients: a three month follow-up

BACKGROUND

Cognitive impairment and deficits in functional performance are major concerns following surgery, particularly for older patients. The objective of this study was to examine predictors of postoperative cognitive and functional difficulties and explore the relationship between presurgery and postsurgery cognitive ability and functional performance.

METHODS

89 patients undergoing elective abdominal aortic aneurysm (AAA) surgery were administered a battery of cognitive measures preoperatively, at the time of discharge from hospital and 3 months postoperatively. Functional performance was evaluated by the Portland Adaptability Inventory (PAI), both pre and postsurgery. Symptoms of delirium were assessed during the first six postoperative days.

RESULTS

A diagnosis of delirium had a mild effect on functional performance 3 months postoperatively. The strongest predictors of postoperative functional performance were the level of functioning presurgery, a longer length of hospital stay and the total number of days delirious. Cognitive impairment postsurgery was predicted by presurgery cognitive measures of verbal memory and psychomotor speed performance and the total number of days delirious.

CONCLUSIONS

Functional performance outcomes for AAA patients 3 months postsurgery revealed no significant loss of functioning relative to presurgery levels, although longer length of hospital stay and greater number of days delirious was associated with somewhat poorer outcome on indicators of social and physical functioning. Cognitive impairment postoperatively was fairly mild but when it was found it was associated with number of days delirious and preoperative deficits in verbal memory and psychomotor speed.

Should endovascular repair be reimbursed for low risk abdominal aortic aneurysm patients? Evidence from ontario, Canada

Background. This paper presents unpublished clinical and economic data associated with open surgical repair (OSR) in low risk (LR) patients and how it compares with EVAR and OSR in high risk (HR) patients with an AAA > 5.5 cm. Design. Data from a 1-year prospective observational study was used to compare EVAR in HR patients versus OSR in HR and LR patients. Results. Between 2003 and 2005, 140 patients were treated with EVAR and 195 with OSR (HR: 52; LR: 143). The 1-year mortality rate with EVAR was statistically lower than HR OSR patients and comparable to LR OSR patients. One-year health-related quality of life was lower in the EVAR patients compared to OSR patients. EVAR was cost-effective compared to OSR HR but not when compared to OSR LR patients. Conclusions. Despite a similar clinical effectiveness, these results suggest that, at the current price, EVAR is more expensive than open repair for low risk patients.

Patients' experience of open repair of abdominal aortic aneurysm--preoperative information, hospital care and recovery

AIMS AND OBJECTIVES

The aim was to elucidate patients' lived experience of the care pathway of going through open surgery for abdominal aortic aneurysm.

BACKGROUND

Open surgical treatment has a great impact on patients' health-related quality of life both before and after treatment. The transition from being independent and asymptomatic to dependent on nursing care can be difficult. To facilitate this process and provide high-quality care, patients' needs must be better understood.

DESIGN

An exploratory descriptive design was chosen to describe and understand patients' lived experience.

METHOD

Audio-taped interviews were performed three months postoperatively, covering the care pathway before and after surgery. Interviews were analysed with qualitative content analysis.

RESULTS

The informants made a transition from becoming aware of the deadly risk associated with abdominal aortic aneurysm to gradually understanding the physical and emotional impact of the surgical procedure during the recovery process. The experience of not understanding fully the risks of undergoing surgery or its consequences on daily life made the informants unprepared for complications and limitations during the recovery period. Many concerns emerged, with a need for more dialogue and opportunities to understand their own care than those provided by the health care staff.

CONCLUSIONS

To facilitate the transition process, health care staff should consider patients' unpreparedness for the physical and emotional impact that can follow diagnosis and treatment for abdominal aortic aneurysm and recognise the need for dialogue to enhance participation during recovery.

RELEVANCE TO CLINICAL PRACTICE

Throughout the care pathway, patients' need for information and for opportunities to reflect on bodily and emotional reactions to the diagnosis and treatment of abdominal aortic aneurysm should be recognised by nurses and physicians to support patients getting realistic expectations of the consequences of treatment and facilitate participation in decisions concerning care and medical treatment.

The drama of being diagnosed with an aortic aneurysm and undergoing surgery for two different procedures: open repair and endovascular techniques

The purpose of this study is to describe and interpret what it means for patients to be diagnosed with an abdominal aortic aneurysm (AAA) and how they experience treatment. AAA is usually asymptomatic and often discovered coincidentally in conjunction with a diagnostic workup for other medical problems. Twenty patients who had undergone 2 different surgical procedures were sequentially invited for interviews 1 month following surgery. A hermeneutic approach was used. For all patients three themes emerged: an inability to come to terms with a life-threatening condition, a sense of living on borrowed time, and a sense of being granted a new lease on life. The theme that emerged for patients with open repair was that diagnosis with AAA was an ordeal to endure, while the theme for patients who underwent endovascular treatment was a sense of gratitude, security, and insecurity. Once the aneurysm was discovered patients were convinced that they were both blessed and saved, along with a sense of gratitude. Pre- and postoperative nursing care strategies can be developed based on the findings from this study.

A review of health utilities using the EQ-5D in studies of cardiovascular disease

BACKGROUND

The EQ-5D has been extensively used to assess patient utility in trials of new treatments within the cardiovascular field. The aims of this study were to review evidence of the validity and reliability of the EQ-5D, and to summarise utility scores based on the use of the EQ-5D in clinical trials and in studies of patients with cardiovascular disease.

METHODS

A structured literature search was conducted using keywords related to cardiovascular disease and EQ-5D. Original research studies of patients with cardiovascular disease that reported EQ-5D results and its measurement properties were included.

RESULTS

Of 147 identified papers, 66 met the selection criteria, with 10 studies reporting evidence on validity or reliability and 60 reporting EQ-5D responses (VAS or self-classification). Mean EQ-5D index-based scores ranged from 0.24 (SD 0.39) to 0.90 (SD 0.16), while VAS scores ranged from 37 (SD 21) to 89 (no SD reported). Stratification of EQ-5D index scores by disease severity revealed that scores decreased from a mean of 0.78 (SD 0.18) to 0.51 (SD 0.21) for mild to severe disease in heart failure patients and from 0.80 (SD 0.05) to 0.45 (SD 0.22) for mild to severe disease in angina patients.

CONCLUSIONS

The published evidence generally supports the validity and reliability of the EQ-5D as an outcome measure within the cardiovascular area. This review provides utility estimates across a range of cardiovascular subgroups and treatments that may be useful for future modelling of utilities and QALYs in economic evaluations within the cardiovascular area.

Endovascular Abdominal Aortic Aneurysm Repair: A Community Hospital's Experience

Endovascular abdominal aortic aneurysm repair (EVAR) has become the first-line approach for the treatment of abdominal aortic aneurysms. Outcomes outside of tertiary care settings remain unknown. The purpose of this study is to report the midterm outcomes of EVAR in a community hospital. A retrospective review of 75 elective, consecutive EVARs performed at a single nonacademic community hospital was performed. There were no conversions to open repair during or after endovascular repair. The mean follow-up was 18 months. There were no postoperative ruptures or aneurysm-related deaths. At 24 months, freedom from aneurysm-related death was 100%, freedom from secondary interventions was 91%, and freedom from endoleak was 69%. EVAR in the community setting is a safe and durable procedure, even in a medically high-risk population. Comparable outcomes can be achieved to tertiary care centers, in carefully selected patients with favorable anatomy.

Outcome and quality of life after surgical and endovascular treatment of descending aortic lesions

BACKGROUND

Thoracic endovascular aortic repair (TEVAR) represents an attractive alternative to open aortic repair (OAR). The aim of this study was to assess outcome and quality of life in patients treated either by TEVAR or OAR for diseased descending thoracic aorta.

METHODS

A post hoc analysis of a prospectively collected consecutive series of 136 patients presenting with surgical diseases of the descending aorta between January 2001 and December 2005 was conducted. Fourteen patients were excluded because of involvement of the ascending aorta. Assessed treatment cohorts were TEVAR (n = 52) and OAR (n = 70). Mean follow-up was 34 +/- 18 months. End points were perioperative and late mortality rates and long-term quality of life as assessed by the Short Form Health Survey (SF-36) and Hospital Anxiety and Depression Score questionnaires.

RESULTS

Mean age was significantly higher in TEVAR patients (69 +/- 10 years versus 62 +/- 15 years; p = 0.002). Perioperative mortality rates were 9% (OAR) and 8% (TEVAR), respectively (p = 0.254). Accordingly, cumulative long-term mortality rates were similar in both cohorts. Overall quality-of-life scores were 93 (63-110, OAR) and 83 (60-112, TEVAR), respectively. Normal quality-of-life scores range from 85 to 115. Anxiety and depression scores were not increased after open surgery.

CONCLUSIONS

Thoracic endovascular aortic repair and OAR both provide excellent long-term results in treatment of thoracic aortic disease. Long-term quality of life, however, is reduced after thoracic aortic repair. Interestingly, TEVAR patients did not score higher in overall quality of life despite all advantages of minimized access trauma. Similarly, anxiety and depression scores are not reduced by TEVAR, possibly reflecting a certain caution against the new technology.

A meta-analysis of 21 178 patients undergoing open or endovascular repair of abdominal aortic aneurysm

Background

Several studies have compared outcomes after elective open and endovascular approaches to abdominal aortic aneurysm (AAA) surgery, with varying results.

Methods

A random-effects meta-analysis was undertaken to compare operative outcomes, postoperative complications, 30-day mortality and long-term patient survival after surgery. Endpoints were compared using odds ratios (ORs), weighted mean differences (WMDs) or log hazard ratios (HRs) as appropriate.

Results

Forty-two studies comprising 21 178 patients (10 855 open; 10 323 endovascular) were included. In the elective setting (20 715 patients), the endovascular method was associated with a shorter stay in intensive care (WMD − 36 h; P &lt; 0·001) and a shorter total postoperative stay (WMD − 5·4 days; P &lt; 0·001). Cardiac (OR 1·76; P = 0·002) and respiratory (OR 4·01; P &lt; 0·001) complications were more common after open surgery. In the endovascular group, 30-day mortality was lower (OR 0·46; P &lt; 0·001). Endovascular surgery was also associated with an improved long-term aneurysm-related mortality (HR 0·39; P &lt; 0·001). For ruptured AAA (463 patients), the less invasive operation was associated with a reduced stay in intensive care (WMD − 100·4 h; P = 0·005) and a significantly lower 30-day mortality (OR 0·45; P = 0·005).

Conclusions

The endovascular repair of AAA offers a clear benefit in terms of reduction in postoperative adverse events and 30-day mortality. In the longer term, it is also associated with a reduction in aneurysm-related mortality, but not in all-cause mortality.

Health-related quality of life in survivors of open ruptured abdominal aortic aneurysm repair: A matched, controlled cohort study

OBJECTIVE

The objective of this study was to document the health-related quality of life (HRQOL) for patients who survived operative repair of a ruptured abdominal aortic aneurysm (RAAA) and to compare this with a matched group of patients who survived elective operative repair of an abdominal aortic aneurysm (EAAA).

METHODS

A matched, controlled cohort study of HRQOL was used to compare patients surviving RAAA with an EAAA control group. The study was conducted at two university-affiliated vascular tertiary care referral centers. Survivors of RAAA and EAAA during an 8.5-year period were identified and followed up. The RAAA and EAAA control patients were matched for age, serum creatinine concentration, gender, and duration of follow-up since surgery. HRQOL was measured with the Medical Outcomes Study Short Form-36 Health Survey (SF-36). Scores for the EAAA and RAAA cohorts were also compared with age-corrected SF-36 population scores.

RESULTS

Of 267 patients operated for RAAA during the study period, 130 (49%) survived to hospital discharge. Death after discharge was documented in 35 patients, leaving a potential study population of 95 RAAA survivors. Thirteen were lost to follow-up, seven refused to participate, and four patients were not able to participate. The SF-36 was completed by 71 RAAA patients (75% of surviving RAAA patients). The 71 RAAA survivors and 189 EAAA control patients were similar for seven of eight domains of the SF-36: Physical Function, Role-Physical, Bodily Pain, General Health, Vitality, Mental Health, and Role-Emotional. There was also no difference in the Physical Health Summary and Mental Health Summary scores. The social function component of the SF-36 demonstrated a statistically significant decline in the EAAA group. Both the EAAA and RAAA SF-36 individual and summary scores compared favorably with population norms that were adjusted only for age.

CONCLUSION

Long-term survivors of RAAA enjoy a HRQOL that does not differ significantly from EAAA survivors. Scores for both groups compare favorably with population scores adjusted only for age.

Performance of endovascular aortic aneurysm repair in high-risk patients: Results from the Veterans Affairs National Surgical Quality Improvement Program

OBJECTIVE

Recent results after endovascular abdominal aortic aneurysm repair (EVAR) have brought into question its value in patients deemed at high-risk for surgical intervention. The Department of Veteran Affairs (VA) National Surgical Quality Improvement Program (NSQIP) is the largest prospectively collected and validated United States surgical database representing current clinical practice. The purpose of our study was to evaluate outcomes after elective EVAR performed in high-risk veterans.

METHODS

Using NSQIP data from 123 participating VA hospitals, we retrospectively evaluated patients who underwent elective aneurysm repair from May 2001 to December 2004. High-risk criteria were used to identify a cohort for analysis (EVAR, n = 788; open, n = 1580). High-risk criteria analyzed included age > or =60 years, American Society of Anesthesiology (ASA) classification 3 or 4, and the comorbidity variables of history of cardiac, respiratory, or hepatic disease, cardiac revascularization, renal insufficiency, and low serum albumin level. Our primary end points were 30-day and 1-year all-cause mortality, and we evaluated a secondary end point of perioperative complications. Statistical analysis included univariate analysis and multivariate modeling.

RESULTS

Veterans who were classified as high-risk underwent elective EVAR with significantly lower 30-day (3.4% vs 5.2%, P = .047) and 1-year all-cause mortality (9.5% vs 12.4%, P = .038) than patients having open repair. EVAR was associated with a decrease in 30-day postoperative mortality (adjusted odds ratio [OR], 0.65; 95% confidence interval [CI], 0.42 to 1.03; P = .067) as well as 1-year mortality (adjusted OR, 0.68; 95% CI, 0.51 to 0.91; P = .0094) despite the presence of severe comorbid conditions. The risk of perioperative complications was significantly lower after EVAR (16.2% vs 31.0%; P < .0001; adjusted OR, 0.41; 95% CI, 0.33 to 0.52; P < .0001). A subset analysis of higher-risk patients (ASA 4 and the above comorbidity variables) still demonstrated an acceptable 30-day mortality rate.

CONCLUSION

In veterans deemed high-risk for surgical therapy, outcomes after elective EVAR are excellent, and the procedure is relatively safe in this special patient population. Our retrospective data demonstrate that patients with considerable medical comorbidities and infrarenal abdominal aortic aneurysms benefit from and should be considered for primary EVAR.

Randomized EVAR Trials and Advent of Level I Evidence: A Paradigm Shift in Management of Large Abdominal Aortic Aneurysms?

The recent endovascular aneurysm repair (EVAR) 1 and 2 and Dutch Randomized Endovascular Aneurysm Management (DREAM) trials addressed management of abdominal aortic aneurysms (AAAs) larger than 5.5 cm in diameter. The DREAM and EVAR 1 trials randomized patients appropriate for open repair between endovascular repair (EVAR) and open repair (OR), and the EVAR 2 trial randomized patients unfit for OR between EVAR and conservative nonoperative management (No Rx). The EVAR 1 trial showed a 3% lower initial mortality for EVAR, with a persistent reduction in aneurysm-related death at 4 years. Improvement in overall late survival was not demonstrated. Similarly, the DREAM trial observed an initial mortality advantage for EVAR, but overall 1-year survival was equivalent in both groups. Both trials found significantly higher complication and intervention rates and higher hospital costs with EVAR, and by 1 year a quality of life (QOL) benefit was not evident. The EVAR 2 trial did not demonstrate a survival advantage of EVAR with respect to nonoperative management, while noting that EVAR was associated with greater likelihood of treatment complications, subsequent interventions, and threefold higher costs. Both EVAR trials were limited by long delays between randomization and treatment. Moreover, 27% of patients in EVAR 2 crossed over from nonoperative to endovascular repair, and these patients had a lower procedure mortality from EVAR than those originally assigned to it (2% v 9%). These 47 cases, and the exclusion of 14 patients dying while waiting for EVAR, appears to confer a survival advantage to those receiving EVAR over those receiving no treatment in a post-hoc analysis, but per-protocol analysis of the EVAR 2 trial data performed by the EVAR investigators did not show a significant difference in either all-cause or aneurysm-related mortality. Thus, outcomes of the EVAR 2 trial have not settled the choice between EVAR and no treatment in this scenario to everyone's satisfaction. In patients with large AAAs who are fit for OR, EVAR offers an initial mortality advantage over OR, with a persistent reduction in AAA-related death at 4 years. However, EVAR offers no overall survival benefit, is more costly, and requires more interventions and indefinite surveillance with only a brief QOL benefit. It may or may not offer a mortality benefit over nonoperative management in patients with large AAAs who are unfit for open repair, but the statistical significance of this comparison is inconclusive.

Open Versus Endovascular Abdominal Aortic Aneurysm Repair in VA Hospitals

BACKGROUND

Endovascular abdominal aortic aneurysm repair (EVAR), when compared with conventional open surgical repair, has been shown to reduce perioperative morbidity and mortality. We performed a retrospective cohort study with prospectively collected data from the Department of Veterans Affairs to examine outcomes after elective aneurysm repair.

STUDY DESIGN

We studied 30-day mortality, 1-year survival, and postoperative complications in 1,904 patients who underwent elective abdominal aortic aneurysm repair (EVAR n=717 [37.7%]; open n=1,187 [62.3%]) at 123 Department of Veterans Affairs hospitals between May 1, 2001 and September 30, 2003. We investigated the influence of patient, operative, and hospital variables on outcomes.

RESULTS

Patients undergoing EVAR had significantly lower 30-day (3.1% versus 5.6%, p=0.01) and 1- year mortality rates (8.7% versus 12.1%, p=0.018) than patients having open repair. EVAR was associated with a decrease in 30-day postoperative mortality (adjusted odds ratio[OR]=0.59; 95% CI=0.36, 0.99; p=0.04). The risk of perioperative complications was much less after EVAR (15.5% versus 27.7%; p<0.001; unadjusted OR 0.48; 95% CI=0.38, 0.61; p<0.001). Patients operated on at low volume hospitals (25% of entire cohort) were more likely to have had open repair (31.3% compared with 15.9% EVAR; p<0.001) and a nearly two-fold increase in adjusted 30-day mortality risk (OR=1.9; 95% CI=1.19, 2.98; p=0.006).

CONCLUSIONS

In routine daily practice, veterans who undergo elective EVAR have substantially lower perioperative mortality and morbidity rates compared with patients having open repair. The benefits of a minimally invasive approach were readily apparent in this cohort, but we recommend using caution in choosing EVAR for all elective abdominal aortic aneurysm repairs until longer-term data on device durability are available.

Endovascular repair of abdominal aortic aneurysm in octogenarians: an analysis based on EUROSTAR data

PURPOSE

To investigate the early and late outcome after endovascular treatment of abdominal aortic aneurysm (EVAR) in octogenarians compared with patients aged < 80 years.

METHODS

Patients treated for abdominal aortic aneurysm (AAA) with endovascular repair during the period 1996 to 2004 were collated in the EUROSTAR registry. This study group consisted of 697 patients aged > or = 80 years. Comparison was made with 4198 patients aged < 80 years with regard to the incidence of preoperative characteristics and outcomes of the procedure.

RESULTS

The proportion of octogenarians treated by EVAR increased during the study period, from 11% in the first year to 18% in the last year. Octogenarians more frequently had cardiac disease, impaired renal function, and pulmonary disease (P = .03, P < .0001 and P = .0001). Thirty-two percent of the octogenarians were recorded unfit for open surgery as opposed to 22% in younger patients (P < .0001); they also had a larger aneurysm diameter (62 vs 58 mm, respectively; P < .0001). The 30-day and in-hospital mortality in octogenarians was 5% vs 2% in the younger group (P < .0001). More device-related complications and systemic complications, including cardiac disease, were noted in octogenarians (7% vs 5% and 19% vs 11%, P = .03 and P < .0001, respectively). This group of patients also had a higher incidence of postoperative hemorrhagic complications, including hematoma (7% vs 3%, P < .0001, respectively). No differences in conversion to open repair and post-EVAR rupture rate were observed. Aneurysm-related mortality and late all-cause mortality was 7% vs 3% and 10% vs 7%, both P < .0001.

CONCLUSION

Our study supports that EVAR might be considered when treating elderly patients, provided their aneurysms are anatomically suited for the endovascular technique. The risk for late complications compared with open repair may be outweighed by a lower early mortality as well as a shorter time for physical recovery.

Patients' quality of life after laparoscopic or open cholecystectomy

OBJECTIVE

This study was aimed at evaluating and comparing the quality of life in patients who underwent laparoscopic and open cholecystectomy for chronic cholecystolithiasis.

METHODS

The study included 25 patients with laparoscopic cholecystectomy (LC group) and 26 with open cholecystectomy (OC group). The quality of life was measured with the Gastrointestinal Quality of Life Index (GLQI) preoperatively, thereafter regularly at 2, 5, 10 and 16 weeks after the operation.

RESULTS

The mean preoperative overall GLQI scores were 112.5 and 110.3 in LC and OC group respectively (P>0.05). In the LC group, the mean overall GLQI score reduced slightly to 110.0 two weeks after the operation (P>0.05). The LC group showed significant improvement in overall score and in the aspects of symptomatology, emotional and physiological status from 5 to 16 weeks postoperatively. In the OC group, the GLQI score reduced to 102.0 two weeks after surgery (P<0.05). Significant reductions were shown in the aspects of symptomatology, physiological and social status. The GLQI scores returned to the preoperative level of 115.6 ten weeks after the operation (P>0.05). The patients experienced significant improvements of GLQI sixteen weeks after OC operation (P<0.01~0.05). Within the 10 postoperative weeks, the LC group had significantly higher GLQI scores than the OC group (P<0.05).

CONCLUSIONS

LC can improve the quality of life postoperatively better and more rapidly than OC. The assessment of quality of life assessment is a valid method for measuring the effects of surgical treatment.

Pain and Quality of Life Assessment after Endovascular Versus Open Repair of Abdominal Aortic Aneurysms in Patients at Low Risk

PURPOSE

To compare functional autonomy, quality of life (QOL), and pain control after endovascular and open repair (OR) of abdominal aortic aneurysms.

MATERIALS AND METHODS

Forty patients with a low surgical risk profile and anatomic compatibility for stent-graft therapy were randomized to receive OR or endovascular aneurysm repair (EVAR). Technical and clinical success as well as mortality were assessed in both groups and compared by Kaplan-Meier analysis. Functional autonomy and QOL were assessed by Karnofsky score and Short Form 36 (SF-36) questionnaire. Pain control was assessed by a numeric rating scale and Brief Pain Inventory questionnaire. QOL outcomes by means of the SF-36 and pain questionnaires were compared with use of mixed-effects models for repeated-measures analysis.

RESULTS

All procedures were technically successful in both groups. Three late clinical failures requiring surgical conversion or repeated intervention were observed in the EVAR group and one was observed in the OR group. There was no significant difference between groups in terms of functional autonomy or QOL. No difference in pain level was evident during the early postoperative period, whereas the pain level was lower in the OR group after 1 month. Opioid analgesic drug consumption was significantly greater in the OR group during the postoperative period. Mean hospitalization duration was shorter in the EVAR group than in the OR group (4.5 days +/- 2.4 vs 11.5 days +/- 8.1; P= .001).

CONCLUSION

EVAR has no advantage over OR in patients at low risk in terms of functional autonomy, QOL, and pain control. However, EVAR was associated with shorter hospitalization durations compared with OR.