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Gormley S, Bernau O, Xu W, Khashram M. Propensity score analysis demonstrates no long term survival benefit from contemporary endovascular aneurysm repair compared to open in Aotearoa New Zealand. ANZ J Surg 2024; 94:819-825. [PMID: 38131414 DOI: 10.1111/ans.18815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 11/20/2023] [Accepted: 11/26/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Current guidelines for AAA management are based on landmark trials comparing EVAR and open aneurysm repair (OAR) conducted more than 20 years ago. Important advancements have been made in peri-operative care but the impact of EVAR and OAR on long-term patient survival has not been well reported using contemporary data. The objective of this study was to compare the short and long-term outcomes of OAR and EVAR in the recent era. METHODS This retrospective observational study included all patients undergoing intact AAA repair in NZ from 1st of January 2011 until 31st of December 2019. Data was collected from national administrative and clinical vascular databases and matched using unique identifiers. Time-to-event survival analyses was conducted using cox proportional hazard models to adjust for confounders and propensity score matching were used. RESULTS Two thousand two hundred and ninety-seven patients had an intact AAA repair with a median (IQR) age of 75 (69-80) years; 494 (21.2%) patients were females and 1206 (53%) underwent EVAR. The 30-day mortality for OAR and EVAR was 4.8% and 1.2%. The median (IQR) follow up was 5.2 (2.3-9.2) years. After propensity matching for co-variates, the study cohort consisted of 835 patients in each matched group. Patients undergoing EVAR had a higher overall mortality (HR 1.48 (95% CI: 1.26-1.74) after adjusting for confounders compared to OAR. CONCLUSION Analysis of survival following EVAR and OAR in the current era demonstrates that patients that underwent EVAR had a lower 30-day mortality. However, in the long-term after adjusting for confounders OAR had a better overall survival.
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Affiliation(s)
- Sinead Gormley
- Department of Vascular & Endovascular Surgery, Waikato Hospital, Hamilton, New Zealand
- Faculty of Medical & Health Sciences, University of Auckland, Auckland, New Zealand
| | - Oliver Bernau
- Faculty of Medical & Health Sciences, University of Auckland, Auckland, New Zealand
| | - William Xu
- Faculty of Medical & Health Sciences, University of Auckland, Auckland, New Zealand
| | - Manar Khashram
- Department of Vascular & Endovascular Surgery, Waikato Hospital, Hamilton, New Zealand
- Faculty of Medical & Health Sciences, University of Auckland, Auckland, New Zealand
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2
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Czerny M, Grabenwöger M, Berger T, Aboyans V, Della Corte A, Chen EP, Desai ND, Dumfarth J, Elefteriades JA, Etz CD, Kim KM, Kreibich M, Lescan M, Di Marco L, Martens A, Mestres CA, Milojevic M, Nienaber CA, Piffaretti G, Preventza O, Quintana E, Rylski B, Schlett CL, Schoenhoff F, Trimarchi S, Tsagakis K, Siepe M, Estrera AL, Bavaria JE, Pacini D, Okita Y, Evangelista A, Harrington KB, Kachroo P, Hughes GC. EACTS/STS Guidelines for Diagnosing and Treating Acute and Chronic Syndromes of the Aortic Organ. Ann Thorac Surg 2024:S0003-4975(24)00077-8. [PMID: 38416090 DOI: 10.1016/j.athoracsur.2024.01.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/29/2024]
Affiliation(s)
- Martin Czerny
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany; Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany.
| | - Martin Grabenwöger
- Department of Cardiovascular Surgery, Clinic Floridsdorf, Vienna, Austria; Medical Faculty, Sigmund Freud Private University, Vienna, Austria.
| | - Tim Berger
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany; Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Victor Aboyans
- Department of Cardiology, Dupuytren-2 University Hospital, Limoges, France; EpiMaCT, Inserm 1094 & IRD 270, Limoges University, Limoges, France
| | - Alessandro Della Corte
- Department of Translational Medical Sciences, University of Campania "L. Vanvitelli", Naples, Italy; Cardiac Surgery Unit, Monaldi Hospital, Naples, Italy
| | - Edward P Chen
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Nimesh D Desai
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Julia Dumfarth
- University Clinic for Cardiac Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - John A Elefteriades
- Aortic Institute at Yale New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Christian D Etz
- Department of Cardiac Surgery, University Medicine Rostock, University of Rostock, Rostock, Germany
| | - Karen M Kim
- Division of Cardiovascular and Thoracic Surgery, The University of Texas at Austin/Dell Medical School, Austin, Texas
| | - Maximilian Kreibich
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany; Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Mario Lescan
- Department of Thoracic and Cardiovascular Surgery, University Medical Centre Tübingen, Tübingen, Germany
| | - Luca Di Marco
- Cardiac Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Andreas Martens
- Department of Cardiac Surgery, Klinikum Oldenburg, Oldenburg, Germany; The Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Carlos A Mestres
- Department of Cardiothoracic Surgery and the Robert WM Frater Cardiovascular Research Centre, The University of the Free State, Bloemfontein, South Africa
| | - Milan Milojevic
- Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Christoph A Nienaber
- Division of Cardiology at the Royal Brompton & Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom; National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Gabriele Piffaretti
- Vascular Surgery Department of Medicine and Surgery, University of Insubria School of Medicine, Varese, Italy
| | - Ourania Preventza
- Division of Cardiothoracic Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Eduard Quintana
- Department of Cardiovascular Surgery, Hospital Clinic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Bartosz Rylski
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany; Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Christopher L Schlett
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany; Department of Diagnostic and Interventional Radiology, University Hospital Freiburg, Freiburg, Germany
| | - Florian Schoenhoff
- Department of Cardiac Surgery, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Santi Trimarchi
- Department of Cardiac Thoracic and Vascular Diseases, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Konstantinos Tsagakis
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University Medicine Essen, Essen, Germany
| | - Matthias Siepe
- EACTS Review Coordinator; Department of Cardiac Surgery, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Anthony L Estrera
- STS Review Coordinator; Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at UTHealth Houston, Houston, Texas
| | - Joseph E Bavaria
- Department of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Davide Pacini
- Division of Cardiac Surgery, S. Orsola University Hospital, IRCCS Bologna, Bologna, Italy
| | - Yutaka Okita
- Cardio-Aortic Center, Takatsuki General Hospital, Osaka, Japan
| | - Arturo Evangelista
- Department of Cardiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Vall d'Hebron Institut de Recerca, Barcelona, Spain; Biomedical Research Networking Center on Cardiovascular Diseases, Instituto de Salud Carlos III, Madrid, Spain; Departament of Medicine, Universitat Autònoma de Barcelona, Bellaterra, Spain; Instituto del Corazón, Quirónsalud-Teknon, Barcelona, Spain
| | - Katherine B Harrington
- Department of Cardiothoracic Surgery, Baylor Scott and White The Heart Hospital, Plano, Texas
| | - Puja Kachroo
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St Louis, Missouri
| | - G Chad Hughes
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Duke University, Durham, North Carolina
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3
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Songra LAK, Baker DM, Agu O, Constantinou J, Hynes N. An Analysis of Cost-Effectiveness and Clinical Outcomes of a Comprehensive Aortic Service in a Tertiary Center over One Year. Ann Vasc Surg 2024; 99:125-134. [PMID: 37926139 DOI: 10.1016/j.avsg.2023.09.084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 09/03/2023] [Accepted: 09/05/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND Endovascular aortic repair (EVAR) is an established and attractive alternative to open surgical repair (OSR) of abdominal aortic aneurysms (AAA) due to its superior short-term safety profile. However, opinions are divided regarding its long-term cost-effectiveness. We compared the total yearly cost of running endovascular and OSR services in a single tertiary center to determine whether fenestrated EVAR (FEVAR) represents a clinically efficacious, affordable treatment option. METHODS A single-center retrospective review was performed on 109 patients undergoing a procedure related to index or previous abdominal aortic repair, with 1 year follow-up. Data was collected from the National Vascular Registry and hospital records. The primary outcome was cost per quality-adjusted life year. Secondary outcomes included 30-day mortality and morbidity, reintervention rates, length of hospital stay, aneurysm, and all-cause mortality at 1 year for elective index procedures. RESULTS The average cost per patient of all FEVAR was £16,041.53 (±8,857.54), £13,893.51 (±£21,425.25) for standard EVAR, and £15,357.22 (±£15,904.49) for OSR (FEVAR versus EVAR P = 0.55, FEVAR versus OSR P = 0.83, OSR versus EVAR P = 0.76). Of the secondary outcomes, significant findings included increased length of stay and respiratory morbidity for patients undergoing open versus endovascular repair. There was no significant difference in 30-day or 1-year mortality between groups. CONCLUSIONS FEVAR, EVAR, and OSR all represent cost-effective options for aortic repair with similar outcomes. Our data highlights the potential for FEVAR to present a viable alternative to open repair, particularly in higher-risk groups, when performed in specialist centers.
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Affiliation(s)
- Lalana A K Songra
- Department of Vascular Surgery, Royal Free Hospital NHS Foundation Trust, London, UK
| | - Daryll M Baker
- Department of Vascular Surgery, Royal Free Hospital NHS Foundation Trust, London, UK; UCL Division of Medicine, Royal Free Campus, University College, London, London, UK.
| | - Obiekezie Agu
- Department of Vascular Surgery, Royal Free Hospital NHS Foundation Trust, London, UK
| | - Jason Constantinou
- Department of Vascular Surgery, Royal Free Hospital NHS Foundation Trust, London, UK
| | - Niamh Hynes
- CÚRAM, SFI Research Centre for Medical Devices, Biomedical Sciences, National University of Ireland Galway, Galway, Ireland
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4
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Czerny M, Grabenwöger M, Berger T, Aboyans V, Della Corte A, Chen EP, Desai ND, Dumfarth J, Elefteriades JA, Etz CD, Kim KM, Kreibich M, Lescan M, Di Marco L, Martens A, Mestres CA, Milojevic M, Nienaber CA, Piffaretti G, Preventza O, Quintana E, Rylski B, Schlett CL, Schoenhoff F, Trimarchi S, Tsagakis K. EACTS/STS Guidelines for diagnosing and treating acute and chronic syndromes of the aortic organ. Eur J Cardiothorac Surg 2024; 65:ezad426. [PMID: 38408364 DOI: 10.1093/ejcts/ezad426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 09/15/2023] [Accepted: 12/19/2023] [Indexed: 02/28/2024] Open
Affiliation(s)
- Martin Czerny
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Martin Grabenwöger
- Department of Cardiovascular Surgery, Clinic Floridsdorf, Vienna, Austria
- Medical Faculty, Sigmund Freud Private University, Vienna, Austria
| | - Tim Berger
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Victor Aboyans
- Department of Cardiology, Dupuytren-2 University Hospital, Limoges, France
- EpiMaCT, Inserm 1094 & IRD 270, Limoges University, Limoges, France
| | - Alessandro Della Corte
- Department of Translational Medical Sciences, University of Campania "L. Vanvitelli", Naples, Italy
- Cardiac Surgery Unit, Monaldi Hospital, Naples, Italy
| | - Edward P Chen
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Nimesh D Desai
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Julia Dumfarth
- University Clinic for Cardiac Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - John A Elefteriades
- Aortic Institute at Yale New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA
| | - Christian D Etz
- Department of Cardiac Surgery, University Medicine Rostock, University of Rostock, Rostock, Germany
| | - Karen M Kim
- Division of Cardiovascular and Thoracic Surgery, The University of Texas at Austin/Dell Medical School, Austin, TX, USA
| | - Maximilian Kreibich
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Mario Lescan
- Department of Thoracic and Cardiovascular Surgery, University Medical Centre Tübingen, Tübingen, Germany
| | - Luca Di Marco
- Cardiac Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Andreas Martens
- Department of Cardiac Surgery, Klinikum Oldenburg, Oldenburg, Germany
- The Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Carlos A Mestres
- Department of Cardiothoracic Surgery and the Robert WM Frater Cardiovascular Research Centre, The University of the Free State, Bloemfontein, South Africa
| | - Milan Milojevic
- Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Christoph A Nienaber
- Division of Cardiology at the Royal Brompton & Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, London, UK
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, UK
| | - Gabriele Piffaretti
- Vascular Surgery Department of Medicine and Surgery, University of Insubria School of Medicine, Varese, Italy
| | - Ourania Preventza
- Division of Cardiothoracic Surgery, Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - Eduard Quintana
- Department of Cardiovascular Surgery, Hospital Clinic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Bartosz Rylski
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Christopher L Schlett
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
- Department of Diagnostic and Interventional Radiology, University Hospital Freiburg, Freiburg, Germany
| | - Florian Schoenhoff
- Department of Cardiac Surgery, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Santi Trimarchi
- Department of Cardiac Thoracic and Vascular Diseases, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Konstantinos Tsagakis
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University Medicine Essen, Essen, Germany
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5
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Akintoye OO. Pre-operative Aortic Anatomic Features as Predictors of Clinical Outcomes Following Endovascular Repair of Abdominal Aortic Aneurysm: A Retrospective Cohort Study. Cureus 2023; 15:e46983. [PMID: 38022100 PMCID: PMC10640889 DOI: 10.7759/cureus.46983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/13/2023] [Indexed: 12/01/2023] Open
Abstract
ARTICLE REMOVED.
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6
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Stewart AG, Millard AR. The sinister story of a gauche deliverer and his corrie-fisted tribesmen: Ehud and the left-handed artillery. Laterality 2023:1-17. [PMID: 37139692 DOI: 10.1080/1357650x.2023.2199965] [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: 05/05/2023]
Abstract
Bias against left-handers is well-documented and seen in the etymology of "left" and "right" in most languages. The subject of this study, Ehud, lived between the exodus of the Hebrew slaves from Egypt and the establishment of the Israelite kingdom (c1200-1000 BC), at the transition between the Late Bronze Age and Iron Age 1. His left-handedness was crucial to his deliverance of the proto-nation from tyranny, recorded in Judges in the Hebrew Bible. The description of Ehud as left-handed ('iṭṭēr yaḏ-yεmînô) is used once more in the Hebrew Bible, also in Judges, to describe the artillery of Ehud's tribe. The words apparently mean "bound/restricted in the right hand", sometimes interpreted as "ambidextrous". This is unlikely: ambidexterity is uncommon. The artillery used the sling with either hand, but Ehud used his left (śεm'ōl) hand to draw his sword. śεm'ōl, used throughout the Hebrew Bible, means left, without bias or derogatory implications. We suggest that 'iṭṭēr yaḏ-yεmînô was a right-handed bias towards left-handed people, but Ehud's left-handed victory was recognized as significant. Significant enough that (a) the language changed and the biased description was dropped in favour of simple description, and (b) the army changed with the development of left-handed slingers (artillery).
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Affiliation(s)
- Alex G Stewart
- College of Life and Environmental Science, University of Exeter, Exeter, UK
- Health Protection, Public Health England, Liverpool, UK
| | - Alan R Millard
- Department of Archaeology, Classics and Egyptology, Liverpool University, Liverpool, UK
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Shahin Y, Dixon S, Kerr K, Cleveland T, Goode SD. Endovascular aneurysm repair offers a survival advantage and is cost-effective compared with conservative management in patients physiologically unfit for open repair. J Vasc Surg 2023; 77:386-395.e3. [PMID: 36152982 DOI: 10.1016/j.jvs.2022.09.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 09/08/2022] [Accepted: 09/10/2022] [Indexed: 01/28/2023]
Abstract
OBJECTIVE The endovascular aneurysm repair-2 (EVAR-2) trial suggested that EVAR in patients unfit for open surgical repair (OSR) failed to provide a significant overall survival advantage compared with conservative management. The aim is to compare survival and cost-effectiveness in patients with poor cardiopulmonary exercise test (CPET) metrics who underwent EVAR or were managed conservatively. METHODS A prospective database of all CPETs (1435 patients) performed to assess preoperative fitness for abdominal aortic aneurysm repair was maintained. A total of 350 patients deemed unfit for OSR underwent EVAR or were managed conservatively. A 1:1 propensity-matched analysis incorporating age, gender, anaerobic threshold, and aneurysm size was used to compare survival. Cost-effectiveness analysis was based on the economic model for the National Institute for Health and Care Excellence clinical guideline on abdominal aortic aneurysm treatment. RESULTS Propensity matching produced 122 pairs of patients in the EVAR and conservative management groups. The median overall survival for the EVAR group was significantly longer than that for the conservative management group (84 vs 30 months, P < .001). One-, three-, and five-year mortality in the EVAR group was 7%, 40%, and 68%, respectively, compared with 25%, 68%, and 82% in the conservative management group, all P < .001. The increment cost-effectiveness ratio for EVAR was £8023 (US$11,644) per quality-adjusted life year gained compared with £430,602 (US$624,967) in the National Institute for Health and Care Excellence guideline, which is based on EVAR-2 results. CONCLUSIONS EVAR offers a survival advantage and is cost-effective in selected patients deemed unfit for OSR based on CPET compared with conservative management.
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Affiliation(s)
- Yousef Shahin
- Sheffield Vascular Institute, Northern General Hospitals, Sheffield, UK; Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Simon Dixon
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK; SAMRC/WITS Centre for Health Economics and Decision Science-PRICELESS, Johannesburg, South Africa
| | - Karen Kerr
- Department of Anaesthesia, Sheffield Teaching Hospitals, Sheffield, UK
| | - Trevor Cleveland
- Sheffield Vascular Institute, Northern General Hospitals, Sheffield, UK
| | - Stephen D Goode
- Sheffield Vascular Institute, Northern General Hospitals, Sheffield, UK.
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8
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Chen Q, Zhang Y, Lei K, Fu L, Zhang D, Sun W, Shi C, Niu Q. Efficacy and safety of prophylactic intraoperative sac embolization in EVAR for abdominal aortic aneurysm: A meta-analysis. Front Surg 2023; 9:1027231. [PMID: 36684193 PMCID: PMC9852339 DOI: 10.3389/fsurg.2022.1027231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 10/24/2022] [Indexed: 01/09/2023] Open
Abstract
Objective We aimed to investigate the effectiveness and safety of prophylactic sac embolization during endovascular aneurysm repair (EVAR) in patients suffering from abdominal aortic aneurysms. Methods We performed a systematic literature search of PubMed, Web of Science, EMbase, Cochrane Library, China National Knowledge Infrastructure (CNKI), VIP, Wanfang and China Biomedical Literature Database (CBM) to identify studies evaluating the outcomes of sac embolization vs. no embolization among patients who had received EVAR. The time limit of the search was from the establishing database to July 22, 2022. Outcome measures involved the type II endoleak rate, the other endoleak rate, the reintervention rate, mortality, and operation time. Fixed (no heterogeneity) or random effects models were constructed for each outcome. The outcomes are represented as the odds ratio (OR) with a 95% confidence interval (CI). Results Among the 2,622 studies screened, 13 studies involving 747 participants were included in the review. The incidence of early-term type II endoleak (OR = 0.2, 95% CI (0.13,0.31), P < 0.00001), mid-term type II endoleak (OR = 0.23, 95% CI (0.15,0.37), P < 0.00001), late-term type II endoleak (OR = 0.27, 95% CI (0.16,0.46), P < 0.00001) and reintervention (OR = 0.50, 95% CI (0.37,0.78), P = 0.002) within the sac embolization group were significantly lower than those in the non-embolization group. No significant differences were observed between the two groups were found for the other endoleak rates (OR = 0.67, 95% CI (0.34,1.32), P = 0.25), mortality (OR = 0.64, 95% CI (0.25,1.66), P = 0.36) and operation time operation (MD = 5.76, 95% CI (-8.30,19.83), P = 0.42). Conclusions EVAR combined with sac embolization effectively reduces the incidence of type II endoleak and the reintervention rate without enhancing the operation time. Therefore, more high-quality studies are still needed for validation due to the limited amount and quality of included literature. Systematic Review Registration https://www.crd.york.ac.uk/PROSPERO/, identifier: CRD42022365648.
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Affiliation(s)
- Quan Chen
- Department of Intervention and Vascular Surgery, Dongguan People's Hospital, Dongguan, Guangdong, China
| | - Yuan Zhang
- The First Clinical Medical College of Gansu University of Chinese Medicine(Gansu Provincial Hospital), Lanzhou, Gansu, China
| | - Kangqing Lei
- The First Clinical Medical College of Gansu University of Chinese Medicine(Gansu Provincial Hospital), Lanzhou, Gansu, China
| | - Liangyin Fu
- The First Clinical Medical College of Gansu University of Chinese Medicine(Gansu Provincial Hospital), Lanzhou, Gansu, China
| | - Dengxiao Zhang
- The First Clinical Medical College of Gansu University of Chinese Medicine(Gansu Provincial Hospital), Lanzhou, Gansu, China
| | - Wanli Sun
- Department of Vascular Surgery, Gansu Provincial Hospital, Lanzhou, Gansu, China
| | - Chaohai Shi
- Department of Vascular Surgery, Gansu Provincial Hospital, Lanzhou, Gansu, China
| | - Qibing Niu
- Department of Vascular Surgery, Gansu Provincial Hospital, Lanzhou, Gansu, China,Correspondence: Qibing Niu
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9
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Halvorsen S, Mehilli J, Cassese S, Hall TS, Abdelhamid M, Barbato E, De Hert S, de Laval I, Geisler T, Hinterbuchner L, Ibanez B, Lenarczyk R, Mansmann UR, McGreavy P, Mueller C, Muneretto C, Niessner A, Potpara TS, Ristić A, Sade LE, Schirmer H, Schüpke S, Sillesen H, Skulstad H, Torracca L, Tutarel O, Van Der Meer P, Wojakowski W, Zacharowski K. 2022 ESC Guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery. Eur Heart J 2022; 43:3826-3924. [PMID: 36017553 DOI: 10.1093/eurheartj/ehac270] [Citation(s) in RCA: 239] [Impact Index Per Article: 119.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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10
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Niklas N, Malec M, Gutowski P, Kazimierczak A, Rynio P. Effectiveness of Inferior Mesenteric Artery Embolization on Type II Endoleak-Related Complications after Endovascular Aortic Repair (EVAR): Systematic Review and Meta-Analysis. J Clin Med 2022; 11:jcm11185491. [PMID: 36143138 PMCID: PMC9506400 DOI: 10.3390/jcm11185491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Revised: 09/09/2022] [Accepted: 09/14/2022] [Indexed: 11/16/2022] Open
Abstract
Type II endoleak is one of the most common and problematic complications after endovascular aneurysm repair. It has been suggested that the inferior mesenteric artery (IMA) embolization could prevent further adverse events and postoperative complications. This article is a systematic review and meta-analysis following PRISMA guidelines. The Medline, PubMed, Embase, and Cochrane databases were used to identify studies that investigated the effect of IMA embolization on the occurrence of type II endoleaks and secondary interventions in a group of patients with abdominal aortic aneurysm who underwent EVAR compared with results after EVAR procedure without embolization. A random effects meta-analysis was performed. Of 3510 studies, 6 studies involving 659 patients were included. Meta-analysis of all studies showed that the rate of secondary interventions was smaller in patients with IMA embolization (OR, 0.17; SE, 0.45; 95% CI, 0.07 to 0.41; p < 0.01; I2 = 0%). The occurrence of type II endoleaks was also smaller in the embolization group (OR, 0.37; SE, 0.21; 95% CI, 0.25 to 0.57; p < 0.01; I2 = 16.20%). This meta-analysis suggests that IMA embolization correlates with lower rates of type II endoleaks and secondary interventions.
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Hensley SE, Upchurch GR. Repair of Abdominal Aortic Aneurysms: JACC Focus Seminar, Part 1. J Am Coll Cardiol 2022; 80:821-831. [PMID: 35981826 DOI: 10.1016/j.jacc.2022.04.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 03/29/2022] [Accepted: 04/05/2022] [Indexed: 10/15/2022]
Abstract
Abdominal aortic aneurysms (AAAs), defined by an aortic diameter >3 cm, affect >1 million people in the United States. Risk factors for AAA include male sex, family history of AAA, smoking, Caucasian ethnicity, and age. Patients with known AAA should undergo regular surveillance via ultrasonography. Medical management, including smoking cessation and blood pressure management, is recommended for asymptomatic patients who do not meet the threshold for intervention. Repair options include endovascular aortic repair and open surgical repair, with good outcomes in long-term follow-up. Men with AAA >5.5 cm and women with AAA >5.0 cm in general should undergo elective repair. Medical management, including smoking cessation and blood pressure management, is recommended for asymptomatic patients who do not meet the threshold for intervention.
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Affiliation(s)
- Sara E Hensley
- Department of Surgery, University of Florida College of Medicine, Gainesville, Florida, USA.
| | - Gilbert R Upchurch
- Department of Surgery, University of Florida College of Medicine, Gainesville, Florida, USA
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12
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Comparison of percutaneous and cutdown access‑related minor complications after endovascular aortic repair. Exp Ther Med 2022; 24:626. [DOI: 10.3892/etm.2022.11563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 07/08/2022] [Indexed: 11/05/2022] Open
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13
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Dié Loucou J, Salomon du Mont L, Jazayeri A, Mariet AS, Leboffe M, Blitti C, Delpy JP, Steinmetz E. Evaluation Of The Effectiveness Of Endovascular Treatment Of Type 2 Endoleaks. Ann Vasc Surg 2022:S0890-5096(22)00439-3. [PMID: 35878699 DOI: 10.1016/j.avsg.2022.06.099] [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: 05/04/2022] [Revised: 06/26/2022] [Accepted: 06/30/2022] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Endovascular abdominal aortic aneurysm repair (EVAR) is a safe and minimally invasive alternative to open surgical repair for infra renal aortic aneuvrysm. EVAR requires lifelong post-procedural surveillance. Endoleaks represent the main complication. Type II endoleaks (EL2) are the most frequent and tend to be indolent. Most practitioners do not treat in EL2 as long as they are associated with stable aneurysm diameter. European guidelines recommend treatment in case of aneurysm growth. Several techniques can be offered, such as transarterial embolization and translumbar embolization. This study reports the experience and results of a single center for EL2 endovascular treatment. The aim of this study was to determine more precisely the efficacity of embolization for type 2 endoleaks treatment. MATERIAL AND METHODS A single center cohort of patients treated for EL2 with endovascular technique between 1998 and 2018 was formed to perform a descriptive analysis. Preoperative sizing, risk factors of endoleaks and intraoperative data were collected. CT scans were regularly performed after EVAR to detect endoleak recurrence. Clinical recurrence was defined as the persistence of aneurysm sac growth and radiological recurrence was defined as the occurrence of EL2 on a post-embolization CT scan. Data related to reintervention, overall mortality and aneurysm related mortality were also collected. Kaplan Meier survival analyses were used to determine the rates of reoperation-free survival and recurrence-free survival. RESULTS Six hundred seven patients underwent an endovascular treatment for abdominal aorta aneurysm between 1998 and 2018. One hundred forty-five type 2 endoleaks occurred during this period. Nineteen patients (median age 76 years), underwent endovascular treatment for EL2, with immediate success on 15 patients (8 transarterial embolization, 8 direct sac puncture and 3 combined procedures). During follow-up, 5 patients required a new translumbar embolization and 6 required an open surgery for recurrence of the EL2. Six patients died, 2 of them of causes related to the aneurysm. At 59,6 months median follow-up, 53% of the patients presented a radiologic recurrence, with a sac growth of more than 5 mm since last procedure in 4 patients (24%). CONCLUSION Long term clinical recurrence of type 2 endoleaks treated by endovascular procedures appear to be frequent in our experience, leading to several deaths and requiring open surgical treatment.
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Affiliation(s)
- J Dié Loucou
- Department of vascular surgery - University Hospital, Boulevard de Lattre de Tassigny 21000 Dijon, France
| | - L Salomon du Mont
- Department of vascular surgery - University Hospital, 3 Boulevard Alexandre Fleming, 25000 Besançon, France
| | - A Jazayeri
- Department of vascular surgery - University Hospital, Boulevard de Lattre de Tassigny 21000 Dijon, France
| | - A S Mariet
- Department of public health - University Hospital, Boulevard de Lattre de Tassigny 21000 Dijon, France
| | - M Leboffe
- Department of vascular surgery - University Hospital, Boulevard de Lattre de Tassigny 21000 Dijon, France
| | - C Blitti
- Department of vascular surgery - University Hospital, Boulevard de Lattre de Tassigny 21000 Dijon, France
| | - J P Delpy
- Department of vascular surgery - University Hospital, Boulevard de Lattre de Tassigny 21000 Dijon, France
| | - E Steinmetz
- Department of vascular surgery - University Hospital, Boulevard de Lattre de Tassigny 21000 Dijon, France
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14
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Trends in thoracic aortic aneurysm hospital admissions, interventions and mortality in England between 1998 to 2020: An observational study. Eur J Vasc Endovasc Surg 2022; 64:340-348. [PMID: 35842176 DOI: 10.1016/j.ejvs.2022.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 06/01/2022] [Accepted: 07/10/2022] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To assess trends in thoracic aortic aneurysm (TAA) hospital admissions, interventions, and aneurysm-related mortality (ARM) in England and examine the impact of endovascular repair on mortality for the years 1998 to 2020. METHODS Hospital admission and operative approach (thoracic endovascular aortic repair, TEVAR or open surgical repair, OSR) using Hospital Episodes Statistics (HES), and ARM data from the Office for National Statistics for England (ONS) standardised to the 2013 European Standard Population were analysed using linear regression and Joinpoint regression analyses. ARM was compared between the pre-endovascular era (1998-2008) and the endovascular era (2009-2019). RESULTS A rising trend in in-hospital admission incidence was observed, mainly due non-ruptured admissions (4.11 per 100,000 in 1998 [95% CI 3.71 to 4.50 per 100,000] to 12.61 per 100,000 in 2020 [95% CI 12.00 to 13.21 per 100,000] in 2020; r2 = 0.98; p < .001). Operative interventions increased mainly due to an increase in TEVAR (2.15 per 100,000 [95% CI 1.91 to 2.41 per 100,000] in 2020 vs 0.26 per 100,000 [95% CI 0.16 to 0.36 per 100,000] in 2006; r2 = 0.90; p < .001). Reductions in ARM from TAA were observed for males and females, irrespective of age and rupture status. The greatest reduction in ARM in the endovascular era was observed in females > 80 years, with ruptured disease 15.26 deaths per 100,000 versus 9.50 deaths per 100,000, p < .0001). CONCLUSION A significant increase in hospital admissions for non-ruptured TAA was observed in the last 23 years in England, paralleled by a shift towards endovascular repair, and significant declining trends in ARM irrespective of gender and age. The significant reductions in ASDR from ruptured and non-ruptured TAA in the endovascular era, particularly for females >80 years with ruptured disease affirm the positive impact of an endovascular approach to TAA.
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15
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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.
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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
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16
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Marone EM, Brioschi C, Pallini M, Marazzi G, Chierico S, Rinaldi LF. Mini-surgical access prevents local complications and reduces costs in endovascular aortic repair. Ann Vasc Surg 2022; 86:111-116. [PMID: 35717007 DOI: 10.1016/j.avsg.2022.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 04/28/2022] [Accepted: 05/08/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND This study aims to propose a minimally invasive surgical approach to the common femoral artery in endovascular aortic repair and assess its value by a single-center retrospective study including 118 patients. MATERIALS AND METHODS Between 2017 and 2022, all patients receiving endovascular treatment for thoracic and abdominal aortic aneurysms in our Center had the anterior wall of the common femoral artery exposed, through a 2- 3cm transverse groin incision, instead of a complete surgical cut-down. We access the artery with a purse-string suture, held tight with a tourniquet. After procedure completion, we tie the purse-string closing the arteriotomy. We retrospectively analyzed the cohort of all consecutive patients treated with endovascular aortic repair in this period and recorded primary and assisted technical success, operative time, in-hospital length of stay, access failure, and access-related complications, comparing the results with the current literature. RESULTS All procedures were successful, with no perioperative mortality. Primary technical success was achieved in 116 patients: two required adjunctive procedures. No access failure or access-related complications (thrombosis, groin hematoma, lymphocele, wound dehiscence, or infection) occurred. Two accesses required conversion to complete femoral artery exposure and endarterectomy. Operatory time and length of in-hospital stay were comparable to the outcomes of the major studies reporting on percutaneous access, saving the costs of the closure devices. CONCLUSION Minimally invasive surgical access is safe and feasible for endovascular aortic procedures. Compared to the costs of percutaneous access found in literature, it is cost-effective. It can be chosen whenever the percutaneous approach is not feasible or at high risk of complications.
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Affiliation(s)
- Enrico Maria Marone
- Department of Vascular Surgery, Policlinico di Monza, Monza, Italy; Vascular Surgery, Department of Clinical-Surgical, Diagnostic and Paediatric Sciences, University of Pavia, Pavia, Italy.
| | - Chiara Brioschi
- Department of Vascular Surgery, Policlinico di Monza, Monza, Italy
| | - Maura Pallini
- Department of Vascular Surgery, Policlinico di Monza, Monza, Italy; Vascular Surgery, Department of Clinical-Surgical, Diagnostic and Paediatric Sciences, University of Pavia, Pavia, Italy
| | - Giulia Marazzi
- Department of Vascular Surgery, Policlinico di Monza, Monza, Italy; Vascular Surgery, Department of Clinical-Surgical, Diagnostic and Paediatric Sciences, University of Pavia, Pavia, Italy
| | - Simona Chierico
- Department of Vascular Surgery, Policlinico di Monza, Monza, Italy; Vascular Surgery, Department of Clinical-Surgical, Diagnostic and Paediatric Sciences, University of Pavia, Pavia, Italy
| | - Luigi Federico Rinaldi
- Department of Vascular Surgery, Policlinico di Monza, Monza, Italy; Vascular Surgery, Department of Integrated Surgical and Diagnostic Sciences, University of Genoa, Genoa, Italy
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17
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Cost effectiveness of computed tomography versus ultrasound-based surveillance following endovascular aortic repair of intact infrarenal abdominal aortic aneurysms. J Vasc Surg 2022; 76:707-713.e1. [DOI: 10.1016/j.jvs.2022.02.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 02/28/2022] [Indexed: 11/22/2022]
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18
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Shields GE, Pennington B, Bullement A, Wright S, Elvidge J. Out of Date or Best Before? A Commentary on the Relevance of Economic Evaluations Over Time. PHARMACOECONOMICS 2022; 40:249-256. [PMID: 34866171 DOI: 10.1007/s40273-021-01116-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/16/2021] [Indexed: 05/27/2023]
Abstract
The impact of time on the applicability and relevance of historical economic evaluations can be considerable. Ignoring this may lead to the use of weak or invalid evidence to inform important research questions or resource allocation decisions, as historical economic evaluations may have reached different conclusions compared to if a similar study had been conducted more recently. There are multiple factors that contribute towards evidence becoming outdated including changes to the relevant decision problem (e.g. comparators), changes to parameters (such as costs, utilities and resource use) and methodological updates (e.g. recommendations on uncertainty analysis). Researchers reviewing economic evaluations need to consider whether changes over time would influence the study design and results if the evaluation were repeated, to the extent that it is no longer helpful or informative. In this paper, we summarise these key issues and make recommendations about how and whether researchers can future proof their economic evaluations.
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Affiliation(s)
- Gemma E Shields
- Division of Population Health, Health Services Research, and Primary Care, Manchester Centre for Health Economics, The University of Manchester, Manchester, UK.
| | - Becky Pennington
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Ash Bullement
- School of Health and Related Research, University of Sheffield, Sheffield, UK
- Delta Hat Ltd, Nottingham, UK
| | - Stuart Wright
- Division of Population Health, Health Services Research, and Primary Care, Manchester Centre for Health Economics, The University of Manchester, Manchester, UK
| | - Jamie Elvidge
- Science, Evidence and Analytics Directorate, National Institute for Health and Care Excellence, Manchester, UK
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Creating Interactive Three-Dimensional Applications to Visualise Novel Stent Grafts That Aid in the Treatment of Aortic Aneurysms. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2022; 1356:1-29. [PMID: 35146615 DOI: 10.1007/978-3-030-87779-8_1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Three-Dimensional (3D) medical animations incorporated into applications are highly beneficial for clinical outreach and medical communication purposes that work towards educating the clinician and patient. Aortic aneurysms are a clinically important area to communicate with multiple audiences about various treatment options; both abdominal and thoracic aortic aneurysms were selected to create 3D animations and applications to educate medical professionals and patients regarding treatment options. Fenestrated endovascular aortic repair (FEVAR) and thoracic endovascular aortic repair (TEVAR) are both tried and tested minimally invasive surgical methods for treating thoracic aortic aneurysms respectively. The Terumo Aortic Custom Relay Proximal Scalloped stent graft and Fenestrated Anaconda stent graft were both designed specifically for these procedures; however, it can be difficult to visually communicate to clinicians and patients in a straightforward way how these devices work. Therefore, we have developed two interactive applications that use 3D visualisation techniques to demonstrate how these aortic devices function and are implemented. The objective of these applications is to engage both clinicians and patients, therefore demonstrating that the addition of anatomically accurate 3D visualisations within an interactive interface would have a positive impact on public engagement while also ensuring that clinicians will have the best possible understanding of the potential uses of both devices, enabling them to exploit their key features to effectively broaden the treatable patient population.Detailed anatomical modelling and animation was used to generate realistic and accurate rendered videos showcasing both products. These videos were integrated into an interactive application within a modern, professional graphic interface that allowed the user to explore all aspects of the stent device. The resulting applications were broken down into three modules: deployment, clinical performance and features. Following application development, these applications were evaluated by professionals in the field. Overall, positive feedback was received regarding the user-friendly nature of the applications and highly effective animations to showcase the products. The clinical applications and feature modules were particularly successful, while the deployment modules had a neutral response. Biomedical applications such as these show great potential for communicating the key features of medical devices and promoting discussion between clinicians and patients; further testing would need to be conducted on a larger group of participants in order to validate the learning effectiveness of the applications.
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Sharples L, Sastry P, Freeman C, Gray J, McCarthy A, Chiu YD, Bicknell C, McMeekin P, Vallabhaneni SR, Cook A, Vale L, Large S. Endovascular stent grafting and open surgical replacement for chronic thoracic aortic aneurysms: a systematic review and prospective cohort study. Health Technol Assess 2022; 26:1-166. [DOI: 10.3310/abut7744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
The management of chronic thoracic aortic aneurysms includes conservative management, watchful waiting, endovascular stent grafting and open surgical replacement. The Effective Treatments for Thoracic Aortic Aneurysms (ETTAA) study investigates timing and intervention choice.
Objective
To describe pre- and post-intervention management of and outcomes for chronic thoracic aortic aneurysms.
Design
A systematic review of intervention effects; a Delphi study of 360 case scenarios based on aneurysm size, location, age, operative risk and connective tissue disorders; and a prospective cohort study of growth, clinical outcomes, costs and quality of life.
Setting
Thirty NHS vascular/cardiothoracic units.
Participants
Patients aged > 17 years who had existing or new aneurysms of ≥ 4 cm in diameter in the arch, descending or thoracoabdominal aorta.
Interventions
Endovascular stent grafting and open surgical replacement.
Main outcomes
Pre-intervention aneurysm growth, pre-/post-intervention survival, clinical events, readmissions and quality of life; and descriptive statistics for costs and quality-adjusted life-years over 12 months and value of information using a propensity score-matched subsample.
Results
The review identified five comparative cohort studies (endovascular stent grafting patients, n = 3955; open surgical replacement patients, n = 21,197). Pooled short-term all-cause mortality favoured endovascular stent grafting (odds ratio 0.71, 95% confidence interval 0.51 to 0.98; no heterogeneity). Data on survival beyond 30 days were mixed. Fewer short-term complications were reported with endovascular stent grafting. The Delphi study included 20 experts (13 centres). For patients with aneurysms of ≤ 6.0 cm in diameter, watchful waiting was preferred. For patients with aneurysms of > 6.0 cm, open surgical replacement was preferred in the arch, except for elderly or high-risk patients, and in the descending aorta if patients had connective tissue disorders. Otherwise endovascular stent grafting was preferred. Between 2014 and 2018, 886 patients were recruited (watchful waiting, n = 489; conservative management, n = 112; endovascular stent grafting, n = 150; open surgical replacement, n = 135). Pre-intervention death rate was 8.6% per patient-year; 49.6% of deaths were aneurysm related. Death rates were higher for women (hazard ratio 1.79, 95% confidence interval 1.25 to 2.57; p = 0.001) and older patients (age 61–70 years: hazard ratio 2.50, 95% confidence interval 0.76 to 5.43; age 71–80 years: hazard ratio 3.49, 95% confidence interval 1.26 to 9.66; age > 80 years: hazard ratio 7.01, 95% confidence interval 2.50 to 19.62; all compared with age < 60 years, p < 0.001) and per 1-cm increase in diameter (hazard ratio 1.90, 95% confidence interval 1.65 to 2.18; p = 0.001). The results were similar for aneurysm-related deaths. Decline per year in quality of life was greater for older patients (additional change –0.013 per decade increase in age, 95% confidence interval –0.019 to –0.007; p < 0.001) and smokers (additional change for ex-smokers compared with non-smokers 0.003, 95% confidence interval –0.026 to 0.032; additional change for current smokers compared with non-smokers –0.034, 95% confidence interval –0.057 to –0.01; p = 0.004). At the time of intervention, endovascular stent grafting patients were older (age difference 7.1 years; 95% confidence interval 4.7 to 9.5 years; p < 0.001) and more likely to be smokers (75.8% vs. 66.4%; p = 0.080), have valve disease (89.9% vs. 71.6%; p < 0.0001), have chronic obstructive pulmonary disease (21.3% vs. 13.3%; p = 0.087), be at New York Heart Association stage III/IV (22.3% vs. 16.0%; p = 0.217), have lower levels of haemoglobin (difference –6.8 g/l, 95% confidence interval –11.2 to –2.4 g/l; p = 0.003) and take statins (69.3% vs. 42.2%; p < 0.0001). Ten (6.7%) endovascular stent grafting and 15 (11.1%) open surgical replacement patients died within 30 days of the procedure (p = 0.2107). One-year overall survival was 82.5% (95% confidence interval 75.2% to 87.8%) after endovascular stent grafting and 79.3% (95% confidence interval 71.1% to 85.4%) after open surgical replacement. Variables affecting survival were aneurysm site, age, New York Heart Association stage and time waiting for procedure. For endovascular stent grafting, utility decreased slightly, by –0.017 (95% confidence interval –0.062 to 0.027), in the first 6 weeks. For open surgical replacement, there was a substantial decrease of –0.160 (95% confidence interval –0.199 to –0.121; p < 0.001) up to 6 weeks after the procedure. Over 12 months endovascular stent grafting was less costly, with higher quality-adjusted life-years. Formal economic analysis was unfeasible.
Limitations
The study was limited by small numbers of patients receiving interventions and because only 53% of patients were suitable for both interventions.
Conclusions
Small (4–6 cm) aneurysms require close observation. Larger (> 6 cm) aneurysms require intervention without delay. Endovascular stent grafting and open surgical replacement were successful for carefully selected patients, but cost comparisons were unfeasible. The choice of intervention is well established, but the timing of intervention remains challenging.
Future work
Further research should include an analysis of the risk factors for growth/rupture and long-term outcomes.
Trial registration
Current Controlled Trials ISRCTN04044627 and NCT02010892.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 6. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Linda Sharples
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Priya Sastry
- Department of Cardiac Surgery, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Carol Freeman
- Papworth Trials Unit Collaboration, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Joanne Gray
- Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, UK
| | - Andrew McCarthy
- Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, UK
| | - Yi-Da Chiu
- Papworth Trials Unit Collaboration, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
- Medical Research Council (MRC) Biostatistics Unit, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Colin Bicknell
- Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - Peter McMeekin
- Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, UK
| | - S Rao Vallabhaneni
- Liverpool Vascular & Endovascular Service, Royal Liverpool University Hospital, Liverpool, UK
| | - Andrew Cook
- Wessex Institute, University of Southampton, Southampton, UK
- Southampton Clinical Trials Unit, University of Southampton, Southampton, UK
| | - Luke Vale
- Health Economics Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Stephen Large
- Department of Cardiac Surgery, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
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Nguyen J, Li A, Tam DY, Forbes TL. ANALYSIS OF SPIN IN VASCULAR SURGERY RANDOMIZED CONTROLLED TRIALS WITH NONSIGNIFICANT OUTCOMES. J Vasc Surg 2021; 75:1074-1080.e17. [PMID: 34923067 DOI: 10.1016/j.jvs.2021.09.051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 09/25/2021] [Indexed: 12/17/2022]
Abstract
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.
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Affiliation(s)
| | - Allen Li
- University of Ottawa, Faculty of Medicine
| | - Derrick Y Tam
- Division of Cardiac Surgery, University of Toronto; Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Thomas L Forbes
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network; Department of Surgery, University of Toronto, Toronto, ON, Canada.
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22
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Quality-adjusted life year comparison at medium term follow-up of endovascular versus open surgical repair for abdominal aortic aneurysm in young patients. PLoS One 2021; 16:e0260690. [PMID: 34855851 PMCID: PMC8639078 DOI: 10.1371/journal.pone.0260690] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 11/16/2021] [Indexed: 11/21/2022] Open
Abstract
Objectives This study aimed to compare the quality of life and cost effectiveness between endovascular aneurysm repair (EVAR) and open surgical repair (OSR) in young patients with abdominal aortic aneurysm (AAA). Design This was a single-center, observational, and retrospective study. Materials and methods A retrospective analysis was conducted of patients with AAA, who were <70 years old and underwent EVAR or OSR between January 2012 and October 2016. Only patients with aortic morphology that was suitable for EVAR were enrolled. Data on the complication rates, medical expenses, and expected quality-adjusted life years (QALYs) were collected, and the cost per QALY at three years was compared. Results Among 90 patients with aortic morphology who were eligible for EVAR, 37 and 53 patients underwent EVAR and OSR, respectively. No significant differences were observed in perioperative cardiovascular events and death between the two groups. However, during the follow-up period, patients undergoing OSR showed a significantly lower complication rate (hazard ratio [HR] = 0.11; P = .021). From the three-year cost-effectiveness analysis, the total sum of costs was significantly lower in the OSR group (P < .001) than that in the EVAR group, and the number of QALYs was superior in the OSR group (P = .013). The cost per QALY at three years was significantly lower in the OSR group than that in the EVAR group (mean: $4038 vs. $10 137; respectively; P < .001) Conclusions OSR had lower complication rates and better cost-effectiveness than EVAR Among young patients with feasible aortic anatomy.
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Avril S, Gee MW, Hemmler A, Rugonyi S. Patient-specific computational modeling of endovascular aneurysm repair: State of the art and future directions. INTERNATIONAL JOURNAL FOR NUMERICAL METHODS IN BIOMEDICAL ENGINEERING 2021; 37:e3529. [PMID: 34490740 DOI: 10.1002/cnm.3529] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 08/30/2021] [Indexed: 06/13/2023]
Abstract
Endovascular aortic repair (EVAR) has become the preferred intervention option for aortic aneurysms and dissections. This is because EVAR is much less invasive than the alternative open surgery repair. While in-hospital mortality rates are smaller for EVAR than open repair (1%-2% vs. 3%-5%), the early benefits of EVAR are lost after 3 years due to larger rates of complications in the EVAR group. Clinicians follow instructions for use (IFU) when possible, but are left with personal experience on how to best proceed and what choices to make with respect to stent-graft (SG) model choice, sizing, procedural options, and their implications on long-term outcomes. Computational modeling of SG deployment in EVAR and tissue remodeling after intervention offers an alternative way of testing SG designs in silico, in a personalized way before intervention, to ultimately select the strategies leading to better outcomes. Further, computational modeling can be used in the optimal design of SGs in cases of complex geometries. In this review, we address some of the difficulties and successes associated with computational modeling of EVAR procedures. There is still work to be done in all areas of EVAR in silico modeling, including model validation, before models can be applied in the clinic, but much progress has already been made. Critical to clinical implementation are current efforts focusing on developing fast algorithms that can achieve (near) real-time solutions, as well as ways of dealing with inherent uncertainties related to patient aortic wall degradation on an individualized basis. We are optimistic that EVAR modeling in the clinic will soon become a reality to help clinicians optimize EVAR interventions and ultimately reduce EVAR-associated complications.
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Affiliation(s)
- Stéphane Avril
- Mines Saint-Étienne, Univ Lyon, Univ Jean Monnet, INSERM, Saint-Étienne, France
| | - Michael W Gee
- Mechanics & High Performance Computing Group, Department of Mechanical Engineering, Technical University of Munich, Garching, Germany
| | - André Hemmler
- Mechanics & High Performance Computing Group, Department of Mechanical Engineering, Technical University of Munich, Garching, Germany
| | - Sandra Rugonyi
- Biomedical Engineering Department, Oregon Health & Science University, Portland, Oregon, USA
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Dorweiler B, Mylonas S, Salem O. [Debate on Infrarenal AAA in Young and Fit Patients ('Fit for Open Repair'): Open Repair is Safe and Long-term Results are Better]. Zentralbl Chir 2021; 146:458-463. [PMID: 34666358 DOI: 10.1055/a-1611-0119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Endovascular aortic repair, initially developed for patients at prohibitively high risk for an open repair, has undergone significant technical evolution and refinement and has emerged as the preferred treatment option for patients with an infrarenal aortic aneurysm. However, analysis of long-term data of the randomised studies revealed inferior results with regards to survival and freedom-from-reintervention after eight years. Open aortic repair has been performed for more than seven decades and especially for the younger patients with few comorbidities, results are excellent. Potential drawbacks of open repair like incisional hernias, erectile dysfunction and quality of life can either be effectively prevented (mesh reinforcement) or actually failed to show a significant difference compared to open repair in recent studies. Therefore, meticulous assessment of patient comorbidites using validated parameters is the key element for decision-making and parameters such as young age, low comorbidity profile, large aneurysm and presence of atopic renal arteries or a dominant inferior mesenteric artery should prompt a recommendation of open repair.
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Affiliation(s)
- Bernhard Dorweiler
- Department of Vascular and Endovascular Surgery, Uniklinik Köln, Koln, Deutschland
| | - Spyridon Mylonas
- Department of Vascular and Endovascular Surgery, Uniklinik Köln, Koln, Deutschland
| | - Oroa Salem
- Department of Vascular and Endovascular Surgery, Uniklinik Köln, Köln, Deutschland
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Akpan E, Kitundu J, Ekpo E. Public Health Radiography: A Scoping Review of Benefits, and Growth Opportunities for Radiographers. J Med Imaging Radiat Sci 2021; 52:615-625. [PMID: 34531164 DOI: 10.1016/j.jmir.2021.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 06/17/2021] [Accepted: 08/06/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION There is growing adoption of radiographic techniques in public health to improve outcomes of chronic and communicable diseases. This review examines the applications, benefits, and implications of radiography in public health. It also examines the challenges and potential advanced practice roles for radiographers in public health radiography (PHR). METHODOLOGY Preferred Reporting Items for Systematic Reviews and Meta-Analyses - Scoping review extension (PRISMA- ScR) checklist was employed, and the search was conducted using PubMed, Medline, Web of Science, ScienceDirect, and Google Scholar to identify relevant articles that explored the concept of radiography in public health. Evidence was analysed using an inductive iterative approach. RESULTS Radiographic imaging modalities such as ultrasound, computed tomography, and plain X-ray had wide applicability in public health fields of preventive cardiology, preventive oncology, maternal health, infectious disease epidemiology, and radiographic informatics. PHR effectively reduced mortality, improved outcomes, informed lifestyle changes to mitigate the risk of impending disease. PHR also helped in monitoring disease progression and predicting treatment outcomes. However, evidence establishing a competency framework that supports PHR is scarce. CONCLUSION Radiography makes a significant contribution to public health in reducing mortality and morbidity. Therefore, developing a PHR competency framework can accentuate the contribution Radiographers make to solving public health issues.
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Affiliation(s)
- Eyo Akpan
- Grayscale International Ltd, Lagos, Nigeria.
| | - Jane Kitundu
- Vijibweni District Hospital, Kigamboni Municipal, Dar es Salaam, Tanzania
| | - Ernest Ekpo
- Image Optimisation and Perception Group, Discipline of Medical Imaging Science, School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Cumberland Campus C42
- 75 East Street, Lidcombe, NS, W
- 2141
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Shih CW, Ho ST, Shui HA, Tang CT, Shih CC, Chen TJ, Lin KC, Liang CY, Wang KY. Endovascular aortic repair is a cost-effective option for in-hospital patients with abdominal aortic aneurysm. J Chin Med Assoc 2021; 84:890-899. [PMID: 34261982 DOI: 10.1097/jcma.0000000000000581] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND To investigate the cost-effectiveness of endovascular aortic repair (EVAR) versus open aortic repair (OAR) for abdominal aortic aneurysm (AAA) using incremental costs per decreased in-hospital mortality rate gained through our patients' cohort. METHODS Medical records and healthcare costs of patients with AAA hospitalized between 2010 and 2015 were extracted from the National Health Insurance Research Database (NHIRD) of Taiwan. Multiple regression analysis was applied to adjust for confounding factors and to compare the differences in postoperative clinical outcomes between patients who received EVAR and OAR. The incremental cost-effectiveness ratio (ICER) of EVAR was determined based on the healthcare cost obtained from the analyzed data. RESULTS A total of 2803 AAA patients were identified (n = 559 with ruptured AAA and n = 2244 unruptured AAA). Patients with ruptured AAA who underwent EVAR compared with OAR patients had shorter hospital and intensive care unit (ICU) stays (all p < 0.05). For patients with unruptured AAA, those who received EVAR compared with OAR, the adjusted odds ratio (aOR) of postoperative complications and in-hospital mortality were 0.371 and 0.447 (all p < 0.05). The total direct surgical costs and medical expenses during hospitalization in all AAA patients were higher for the EVAR group; however, ICER was <1 per capita gross domestic product. Stratification by age groups further suggested that ICER for patients with unruptured AAA who received EVAR, compared with OAR, decreased with age. CONCLUSION Total direct medical costs were higher for AAA patients receiving EVAR regardless of rupture status; however, the cost is offset by lower odds of postoperative complications and in-hospital mortality. The observed decrease in ICER with age and EVAR use warrants further analysis. Our findings further validate the use of EVAR over OAR. These results provides supporting evidence for physicians and patients with AAA to inform shared decision making regarding endovascular or OAR options.
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Affiliation(s)
- Chia-Wen Shih
- Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan, ROC
- Department of Nursing, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Shung-Tai Ho
- Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan, ROC
- Department of Anesthesiology, Kaohsiung Medical University Chung-Ho Memorial Hospital, Kaohsiung, Taiwan, ROC
| | - Hao-Ai Shui
- Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Chi-Tun Tang
- Department of Neurological Surgery, National Defense Medical Center, Tri-Service General Hospital, Taipei, Taiwan, ROC
| | - Chun-Che Shih
- Taipei Heart Institute, Taipei Medical University, Division of Cardiovascular Surgery, Taipei, Taiwan, ROC
- Department of Surgery, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan, ROC
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Tzeng-Ji Chen
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Family Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Kuan-Chia Lin
- Institute of Hospital and Health Care Administration, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Community Medicine Research Center, Taipei, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Chun-Yu Liang
- School of Nursing, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Kwua-Yun Wang
- Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan, ROC
- Department of Nursing, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Nursing, National Defense Medical Center, Taipei, Taiwan, ROC
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Kreibich M, Siepe M, Berger T, Pingpoh C, Puiu P, Morlock J, Walter T, Kondov S, Beyersdorf F, Rylski B, Czerny M. Treatment of infectious aortic disease with bovine pericardial tube grafts. Eur J Cardiothorac Surg 2021; 60:155-161. [PMID: 33523214 DOI: 10.1093/ejcts/ezab003] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 11/20/2020] [Accepted: 12/08/2020] [Indexed: 01/29/2023] Open
Abstract
OBJECTIVES Our aim was to evaluate the mid-term outcomes of bovine pericardial tube graft repair for infectious aortic disease in any aortic segment. METHODS Between May 2015 and July 2020, 45 patients were treated for infectious aortic disease of the native (n = 9) aorta or after (endo-)graft (n = 36) implantation with bovine pericardial tube grafts. Clinical, infectious details, outcomes and follow-up data were evaluated. RESULTS All aortic segments underwent pericardial tube graft or bifurcational replacement: the aortic root (n = 12, 27%), ascending aorta (n = 18, 40%), aortic arch (n = 7, 16%), descending aorta (n = 5, 11%), thoraco-abdominal aorta (n = 6, 13%) and abdominal aorta (n = 18, 40%) including the iliac arteries (n = 14, 31%). Organ fistulation (n = 15, 33%) was the most common underlying pathology. Seven patients (16%) expired in-hospital secondary to ongoing sepsis (n = 5, 11%), respiratory failure (n = 1, 2%) and unknown cause (n = 1, 2%). A fungal infection was predictive for in-hospital mortality (P = 0.026, odds ratio: 19.470). After a median follow-up of 11 [first quartile: 2, third quartile 26] months, 9 additional patients (20%) expired and 1 patient developed a postoperative spondylodiscitis at the level of the aortic tube graft. Hence, freedom from proven aortic graft re-infection was 98%. CONCLUSIONS Orthotopic aortic reconstruction using bovine pericardial tube grafts to treat infectious aortic disease is possible in any aortic segment. Organ fistulation is a frequently observed disease mechanism requiring concomitant treatment. Granted, the early attrition rate is substantial, but after the initial period, both survival and freedom from re-infection appear encouraging.
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Affiliation(s)
- Maximilian Kreibich
- Department of Cardiovascular Surgery, Heart Centre Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Matthias Siepe
- Department of Cardiovascular Surgery, Heart Centre Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Tim Berger
- Department of Cardiovascular Surgery, Heart Centre Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Clarence Pingpoh
- Department of Cardiovascular Surgery, Heart Centre Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Paul Puiu
- Department of Cardiovascular Surgery, Heart Centre Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Julia Morlock
- Department of Cardiovascular Surgery, Heart Centre Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Tim Walter
- Department of Cardiovascular Surgery, Heart Centre Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Stoyan Kondov
- Department of Cardiovascular Surgery, Heart Centre Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, Heart Centre Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Bartosz Rylski
- Department of Cardiovascular Surgery, Heart Centre Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Martin Czerny
- Department of Cardiovascular Surgery, Heart Centre Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Endovascular Aortic Aneurysm Repair during the Early Days of the COVID-19 Outbreak. JOURNAL OF CARDIOVASCULAR EMERGENCIES 2021. [DOI: 10.2478/jce-2021-0007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Introduction: We report the results of endovascular aortic repair (EVAR) in three patients during the COVID-19 pandemic. Materials and Methods: Three patients were diagnosed with abdominal aortic aneurysm. All three patients were male and aged 68 years. The diameter of the aneurysm was larger than 65 mm and was considered suitable for EVAR. Thorax tomography was performed to exclude SARS-CoV-2 infection before the procedure. Results: We performed EVAR under general anesthesia. “Priority Level” was based on the guideline of the American College of Surgeons. The procedure was conducted in the angiography laboratory by taking advanced precautions. Intensive care admission was avoided. The postoperative period was uneventful, and all patients were discharged without any condition associated with COVID-19. There were no mortality, rupture, secondary intervention, major adverse event, limb occlusion, and 60-day read-mission. Conclusions: During the pandemic, EVAR can be performed for symptomatic abdominal aortic aneurysm with a diameter of more than 65 mm. Thorax tomography is safe to exclude SARS-CoV-2 infection. However, tomographic angiography to monitor patients may be difficult during the pandemic.
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Fenton C, Tan AR, Abaraogu UO, McCaslin JE. Prehabilitation exercise therapy before elective abdominal aortic aneurysm repair. Cochrane Database Syst Rev 2021; 7:CD013662. [PMID: 34236703 PMCID: PMC8275457 DOI: 10.1002/14651858.cd013662.pub2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND An abdominal aortic aneurysm (AAA) is an abnormal dilation in the diameter of the abdominal aorta of 50% or more of the normal diameter or greater than 3 cm in total. The risk of rupture increases with the diameter of the aneurysm, particularly above a diameter of approximately 5.5 cm. Perioperative and postoperative morbidity is common following elective repair in people with AAA. Prehabilitation or preoperative exercise is the process of enhancing an individual's functional capacity before surgery to improve postoperative outcomes. Studies have evaluated exercise interventions for people waiting for AAA repair, but the results of these studies are conflicting. OBJECTIVES To assess the effects of exercise programmes on perioperative and postoperative morbidity and mortality associated with elective abdominal aortic aneurysm repair. SEARCH METHODS We searched the Cochrane Vascular Specialised register, Cochrane Central Register of Controlled Trials, MEDLINE, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and Physiotherapy Evidence Database (PEDro) databases, and the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 6 July 2020. We also examined the included study reports' bibliographies to identify other relevant articles. SELECTION CRITERIA We considered randomised controlled trials (RCTs) examining exercise interventions compared with usual care (no exercise; participants maintained normal physical activity) for people waiting for AAA repair. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies for inclusion, assessed the included studies, extracted data and resolved disagreements by discussion. We assessed the methodological quality of studies using the Cochrane risk of bias tool and collected results related to the outcomes of interest: post-AAA repair mortality; perioperative and postoperative complications; length of intensive care unit (ICU) stay; length of hospital stay; number of days on a ventilator; change in aneurysm size pre- and post-exercise; and quality of life. We used GRADE to evaluate certainty of the evidence. For dichotomous outcomes, we calculated the risk ratio (RR) with the corresponding 95% confidence interval (CI). MAIN RESULTS This review identified four RCTs with a total of 232 participants with clinically diagnosed AAA deemed suitable for elective intervention, comparing prehabilitation exercise therapy with usual care (no exercise). The prehabilitation exercise therapy was supervised and hospital-based in three of the four included trials, and in the remaining trial the first session was supervised in hospital, but subsequent sessions were completed unsupervised in the participants' homes. The dose and schedule of the prehabilitation exercise therapy varied across the trials with three to six sessions per week and a duration of one hour per session for a period of one to six weeks. The types of exercise therapy included circuit training, moderate-intensity continuous exercise and high-intensity interval training. All trials were at a high risk of bias. The certainty of the evidence for each of our outcomes was low to very low. We downgraded the certainty of the evidence because of risk of bias and imprecision (small sample sizes). Overall, we are uncertain whether prehabilitation exercise compared to usual care (no exercise) reduces the occurrence of 30-day (or longer if reported) mortality post-AAA repair (RR 1.33, 95% CI 0.31 to 5.77; 3 trials, 192 participants; very low-certainty evidence). Compared to usual care (no exercise), prehabilitation exercise may decrease the occurrence of cardiac complications (RR 0.36, 95% CI 0.14 to 0.92; 1 trial, 124 participants; low-certainty evidence) and the occurrence of renal complications (RR 0.31, 95% CI 0.11 to 0.88; 1 trial, 124 participants; low-certainty evidence). We are uncertain whether prehabilitation exercise, compared to usual care (no exercise), decreases the occurrence of pulmonary complications (RR 0.49, 95% 0.26 to 0.92; 2 trials, 144 participants; very low-certainty evidence), decreases the need for re-intervention (RR 1.29, 95% 0.33 to 4.96; 2 trials, 144 participants; very low-certainty evidence) or decreases postoperative bleeding (RR 0.57, 95% CI 0.18 to 1.80; 1 trial, 124 participants; very low-certainty evidence). There was little or no difference between the exercise and usual care (no exercise) groups in length of ICU stay, length of hospital stay and quality of life. None of the studies reported data for the number of days on a ventilator and change in aneurysm size pre- and post-exercise outcomes. AUTHORS' CONCLUSIONS Due to very low-certainty evidence, we are uncertain whether prehabilitation exercise therapy reduces 30-day mortality, pulmonary complications, need for re-intervention or postoperative bleeding. Prehabilitation exercise therapy might slightly reduce cardiac and renal complications compared with usual care (no exercise). More RCTs of high methodological quality, with large sample sizes and long-term follow-up, are needed. Important questions should include the type and cost-effectiveness of exercise programmes, the minimum number of sessions and programme duration needed to effect clinically important benefits, and which groups of participants and types of repair benefit most.
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Affiliation(s)
- Candida Fenton
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Audrey R Tan
- Institute of Health Informatics Research, University College London, London, UK
| | - Ukachukwu Okoroafor Abaraogu
- Department of Physiotherapy and Paramedicine, School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
- Department of Medical Rehabilitation, University of Nigeria, Nsukka, Nigeria
| | - James E McCaslin
- Northern Vascular Centre, Freeman Hospital, Newcastle upon Tyne, UK
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Nargesi S, Abutorabi A, Alipour V, Tajdini M, Salimi J. Cost-Effectiveness of Endovascular Versus Open Repair of Abdominal Aortic Aneurysm: A Systematic Review. Cardiovasc Drugs Ther 2021; 35:829-839. [PMID: 33559809 DOI: 10.1007/s10557-020-07130-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/11/2020] [Indexed: 12/01/2022]
Abstract
PURPOSE Abdominal aortic aneurysm (AAA) is a life-threatening condition which, in the absence of increasing diameter or rupture, often remains asymptomatic, and a diameter greater than 5.5 cm requires elective surgical repair. This study aimed to evaluate the cost-effectiveness of endovascular repair (EVAR) versus open surgical repair (OSR) in patients with AAA through a systematic review of published health economics studies. METHODS Using a systematic review method, an electronic search was conducted for cost-effectiveness studies published on AAA (both in English and Persian) on PubMed, Embase, ISI/Web of Science (WoS), SCOPUS, Global Health databases, and the national databases of Iran from 1990 to 2020 including the keywords "cost-effectiveness", "endovascular", "open surgical", and "abdominal aortic aneurysms". The quality of the studies was assessed using the Quality of Health Economic Studies (QHES) checklist. RESULTS In total, 958 studies were found, of which 16 were eligible for further study. All studies were conducted in developed countries, and quality-adjusted life years (QALY) and life years (LY) were used to measure the outcomes. According to the QHES checklist, most studies were of good quality. In European countries and Canada, EVAR has not been cost-effective, while most studies in the United States regard this technique as a cost-effective intervention. For example, incremental cost-effectiveness ratio (ICER) values ranged from $14,252.12 to $34,446.37 per QALY in the USA, while ICER was €116,600.40 per QALY in Portugal. CONCLUSION According to the results, the EVAR technique has been more cost-effective than OSR for high-risk patients, but the need for continuous follow-up, increased costs, and re-intervention over the long term and for low-risk patients has reduced the cost-effectiveness of this method. As the health systems vary among different countries (i.e. quality of care, cost of devices, etc.), and due to the heterogeneity of studies in terms of the follow-up period, time horizon, and threshold, all of which are inherent features of economic evaluation, generalizing the results should be done with much caution, and policymaking must be based on national evidence.
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Affiliation(s)
- Shahin Nargesi
- Department of Health Economics, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Ali Abutorabi
- Health Management and Economics Research Center, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran.
| | - Vahid Alipour
- Health Management and Economics Research Center, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Masih Tajdini
- Department of Cardiology, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Javad Salimi
- Vascular Surgery Department, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
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The Effect of Patient Oral Intake Status on Abdominal Aortic Ultrasound Visualization. Ann Vasc Surg 2021; 74:204-208. [PMID: 33556518 DOI: 10.1016/j.avsg.2020.12.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 12/17/2020] [Accepted: 12/17/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND The standard abdominal aortic duplex ultrasound protocol requires fasting for 8-12 hours prior to examination in attempt to reduce bowel gas and improve visualization. Such practice results in frequent testing delays and patient non-compliance. The aim of this study was to determine whether fasting improves visualization of the abdominal aorta in patients undergoing duplex ultrasound or influences diagnostic properties. METHODS This was a prospective, randomized, double-blind imaging trail at a single institution. Ninety patients were randomized to one of three dietary groups, including NPO, clear liquids or control (regular diet). Diagnostic ultrasound examinations were performed by accredited Registered Vascular Technologists who remained blinded to the patients' diet. Sonographers commented on the presence of limited visualization in the study based on their ability to accurately measure aortic diameter. Examination results were randomly assigned to interpreting physicians who were also blinded to the patients' diet. Following interpretation, the reading physician was asked to comment whether they had sufficient information for a conclusive diagnostic interpretation. RESULTS All ultrasound studies were deemed diagnostic by the interpreting physician regardless of the patients' dietary status. Limited visualization was reported in 19 of the 90 study patients (21.1%) with no significant difference existing between the dietary groups (P = 0.344). The NPO group contained the most patients with studies deemed to have limited visualization. CONCLUSION Oral intake status did not affect visualization of the abdominal aorta or the rate of diagnostic studies in patients undergoing DUS at a single center. These results suggest that dietary restrictions prior to DUS evaluation of the abdominal aorta is unnecessary.
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Silingardi R, Andreoli F, Saitta GM, Leone N, Migliari M, Gennai S. Twenty years outcomes in a single center experience after endovascular aneurysm repair with unibody endograft and anatomical fixation. THE JOURNAL OF CARDIOVASCULAR SURGERY 2021; 61:720-728. [DOI: 10.23736/s0021-9509.19.11076-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Spanos K, Behrendt CA, Kouvelos G, Giannoukas AD, Kölbel T. A new randomized controlled trial on abdominal aortic aneurysm repair is needed. J Vasc Surg 2020; 72:2145-2148. [DOI: 10.1016/j.jvs.2020.06.102] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Accepted: 06/05/2020] [Indexed: 12/22/2022]
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Zoethout AC, Sheriff A, Zeebregts CJ, Reijnen MMPJ, Hill A, Holden A. Migration After Endovasclar Aneurysm Sealing in Conjunction With Chimney Grafts. J Endovasc Ther 2020; 28:165-172. [PMID: 32909531 PMCID: PMC7816544 DOI: 10.1177/1526602820957279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Purpose To assess the incidence of migration after endovascular aneurysm sealing (EVAS) in conjunction with chimney grafts (chEVAS) for repair of abdominal aortic aneurysms (AAAs). Materials and Methods A retrospective, observational cohort study was conducted of 31 patients (mean age 75.7 years; 27 men) treated for juxtarenal AAA between April 2013 and December 2018 at single centers in New Zealand and the Netherlands. The majority of patients received >1 chimney graft (13 single, 13 double, and 5 triple) during chEVAS. Six patients had only the first postoperative scan, so the migration analysis was based on 25 patients. Results Median seal length assessed on the first postoperative computed tomography scan was 36.5 mm. The assisted technical success rate was 93.5% with 2 technical failures. Median time to final imaging follow-up was 17 months in 25 patients. At the latest follow-up, there were no cases of caudal migration >10 mm. Freedom from caudal movement of 5 to 9 mm was estimated as 86.1% at 1 year and 73.9% at 2 years; freedom from clinically relevant migration (movement requiring reintervention) was 100% at both time intervals. However, at 3 years there were 2 cases of caudal movement of 5 to 9 mm and a type Ia endoleak warranting reintervention. No correlation between migration and aneurysm growth (p=0.851), endoleak (p=0.562), or the number of chimney grafts (p=0.728) was found. During follow-up, 2 patients (7%) had aneurysm rupture and 10 (33%) had reinterventions. Eight patients (27%) died; 2 were aneurysm-related (7%) and due to the consequences of a reintervention. Conclusion In the 2 years following chEVAS, there was no caudal migration >10 mm, but nearly a quarter of patients had caudal movement of 5 to 9 mm. A trend was observed toward ongoing migration that required intervention at 3-year follow-up. chEVAS is technically challenging and should be considered only for patients with no viable alternative treatment option.
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Affiliation(s)
- Aleksandra C Zoethout
- Department of Interventional Radiology and Vascular Surgery, Auckland City Hospital, Auckland, New Zealand.,Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, University of Groningen, the Netherlands.,Department of Vascular Surgery, Rijnstate Hospital, Arnhem, the Netherlands
| | - Arshad Sheriff
- Department of Interventional Radiology and Vascular Surgery, Auckland City Hospital, Auckland, New Zealand
| | - Clark J Zeebregts
- Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, University of Groningen, the Netherlands
| | - Michel M P J Reijnen
- Department of Vascular Surgery, Rijnstate Hospital, Arnhem, the Netherlands.,MultiModality Medical Imaging Group, TechMed Centre, University of Twente, Enschede, the Netherlands
| | - Andrew Hill
- Department of Interventional Radiology and Vascular Surgery, Auckland City Hospital, Auckland, New Zealand
| | - Andrew Holden
- Department of Interventional Radiology and Vascular Surgery, Auckland City Hospital, Auckland, New Zealand
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Wanken ZJ, Barnes JA, Trooboff SW, Columbo JA, Jella TK, Kim DJ, Khoshgowari A, Riblet NB, Goodney PP. A systematic review and meta-analysis of long-term reintervention after endovascular abdominal aortic aneurysm repair. J Vasc Surg 2020; 72:1122-1131. [DOI: 10.1016/j.jvs.2020.02.030] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 02/03/2020] [Indexed: 01/12/2023]
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Sen I, Tenorio ER, Mirza AK, Kärkkäinen JM, Mendes BC, DeMartino RR, Cha S, Oderich GS. Effect of Blood Loss and Transfusion Requirements on Clinical Outcomes of Fenestrated-Branched Endovascular Aortic Repair. Cardiovasc Intervent Radiol 2020; 43:1600-1607. [PMID: 32864718 DOI: 10.1007/s00270-020-02573-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 06/22/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the effect of blood loss and transfusion requirements on clinical outcomes of patients treated by fenestrated-branched endovascular aortic repair (F-BEVAR) for pararenal (PRA) and thoracoabdominal aortic aneurysms (TAAAs). METHODS We reviewed the clinical data of 370 consecutive patients (277 male, mean age 74 ± 10 years) treated by F-BEVAR between 2007 and 2017. Outcomes were estimated blood loss (EBL), use of intraoperative blood salvage (IOBS), transfusion of packed red blood cells (PRBCs), mortality, and major adverse events (MAEs). RESULTS There were 189 patients (51%) treated for PRAs and 181 patients (49%) treated for TAAAs. IOBS was used in 194 patients (52%) and transfusion of PRBCs was needed in 137 (37%). Thirty-day mortality was 2.2% (8/370) and MAEs occurred in 123 patients (33%), including 74 patients (20%) who had EBL > 1L. EBL > 1L and transfusion of PRBCs were significantly higher (P < 0.05) in patients treated in the first half of clinical experience and in those with larger aneurysms, iliofemoral conduits, bilateral open surgical femoral access and Extent I-III TAAAs. Use of DrySeal® sheaths (WL Gore, Flagstaff AZ) was associated with significantly lower (P < .05) EBL volume and with less transfusion of PRBCs. On multivariate analysis PRBCs > 1L, male gender and the last half of clinical experience were associated with MAEs/mortality. CONCLUSIONS F-BEVAR was associated with significantly higher volume of blood loss and transfusion requirements in patients treated in the early experience and in those who had iliofemoral conduits, open femoral surgical exposure or Extent I-III TAAAs.
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Affiliation(s)
- Indrani Sen
- Advanced Endovascular Aortic Research Program, Mayo Clinic, Rochester, MN, USA
| | - Emanuel R Tenorio
- Advanced Aortic Research Program, University of Texas Health Science at Houston, McGoven Medical School, Houston, TX, USA
| | - Aleem K Mirza
- Advanced Endovascular Aortic Research Program, Mayo Clinic, Rochester, MN, USA
| | - Jussi M Kärkkäinen
- Advanced Endovascular Aortic Research Program, Mayo Clinic, Rochester, MN, USA
| | - Bernardo C Mendes
- Advanced Endovascular Aortic Research Program, Mayo Clinic, Rochester, MN, USA
| | - Randall R DeMartino
- Advanced Endovascular Aortic Research Program, Mayo Clinic, Rochester, MN, USA
| | - Stephen Cha
- Advanced Endovascular Aortic Research Program, Mayo Clinic, Rochester, MN, USA
| | - Gustavo S Oderich
- Advanced Aortic Research Program, University of Texas Health Science at Houston, McGoven Medical School, Houston, TX, USA. .,Memorial Hermann Medical Plaza, University of Texas Health Science, Houston, TX, USA.
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Fenton C, Abaraogu UO, Tan AR, McCaslin JE. Prehabilitation exercise therapy before abdominal aortic aneurysm repair. Hippokratia 2020. [DOI: 10.1002/14651858.cd013662] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Affiliation(s)
- Candida Fenton
- Usher Institute of Population Health Sciences and Informatics; University of Edinburgh; Edinburgh UK
| | - Ukachukwu Okoroafor Abaraogu
- Department of Physiotherapy and Paramedicine, School of Health and Life Sciences; Glasgow Caledonian University; Glasgow UK
- Department of Medical Rehabilitation; University of Nigeria; Nsukka Nigeria
| | - Audrey R Tan
- Institute of Health Informatics Research; University College London; London UK
| | - James E McCaslin
- Northern Vascular Centre; Freeman Hospital; Newcastle upon Tyne UK
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Eleshra A, Oderich GS, Spanos K, Panuccio G, Kärkkäinen JM, Tenorio ER, Kölbel T. Short-term outcomes of the t-Branch off-the-shelf multibranched stent graft for reintervention after previous infrarenal aortic repair. J Vasc Surg 2020; 72:1558-1566. [PMID: 32423775 DOI: 10.1016/j.jvs.2020.02.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 02/03/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate the outcome of t-Branch (Cook Medical, Bloomington, Ind) stent graft for the treatment of thoracoabdominal and pararenal aortic aneurysms in patients who had previous infrarenal aortic repair. METHODS A retrospective two-center study was undertaken. All consecutive patients who underwent endovascular repair using t-Branch stent graft after previous infrarenal aortic repair between January 2010 and August 2018 were included. Demographics, past medical history, cardiovascular risk factors, and intraoperative and perioperative details were recorded. Technical success and early (30-day) mortality, morbidity, target vessel patency, and presence of endoleak were analyzed. During the first year of follow-up, survival, freedom from reintervention, and patency rates were recorded. RESULTS There were 32 patients (mean age, 74 ± 7 years; 81% male) included in the study; 24 (75%) patients had prior open surgical repair, and 8 (25%) patients had undergone standard endovascular aneurysm repair. The index operation was performed 9 ± 5 years earlier, including 10 ± 5 years for open surgical repair and 8 ± 6 years for endovascular aortic repair. The indication was progression of the disease in 26 patients (81%) and type IA endoleak in 6 patients (19%). The total number of target vessels incorporated was 117 arteries (3.8 ± 0.6 target vessels per patient). Eleven patients had only three vessels incorporated; celiac trunk was occluded in three patients, and eight patients had one functioning kidney. Technical success rate was 97% (31/32). There was a single technical failure in one patient who had a type IA endoleak after endovascular repair with suprarenal fixation. The stenotic right renal artery was not catheterized at the initial procedure, and retrograde access was achieved through a right subcostal incision 3 days later with successful completion of the repair. Early mortality rate was 13%, and spinal cord ischemia rate was 22% (7/32); four patients had permanent and three had transient neurologic deficits. Early target vessel patency was 100%, and the rate of any endoleak was 9% (3/32); two patients had type II endoleaks and one patient had type III endoleak. The mean follow-up was 5.4 ± 5.9 months. The cumulative survival rate was 82% and 73% at 6 and 12 months, respectively. The freedom from aorta-related mortality was 92% at 6 and 12 months. The cumulative freedom from reintervention during follow-up was 90% at 6 and 12 months. The overall target vessel patency rate was 100% and 97.5% at 6 and 12 months, respectively. CONCLUSIONS The use of t-Branch off-the-shelf stent graft for the treatment of aortic disease in patients who had previous infrarenal aortic repair appears to be feasible, with acceptable early outcomes in terms of morbidity and mortality.
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Affiliation(s)
- Ahmed Eleshra
- Department of Vascular Medicine, German Aortic Center, University Heart & Vascular Center Hamburg, Hamburg, Germany.
| | - Gustavo S Oderich
- Division of Vascular and Endovascular Surgery, Advanced Endovascular Aortic Research Program, Mayo Clinic, Rochester, Minn
| | - Konstantinos Spanos
- Department of Vascular Medicine, German Aortic Center, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Giuseppe Panuccio
- Department of Vascular Medicine, German Aortic Center, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Jussi M Kärkkäinen
- Division of Vascular and Endovascular Surgery, Advanced Endovascular Aortic Research Program, Mayo Clinic, Rochester, Minn
| | - Emanuel R Tenorio
- Division of Vascular and Endovascular Surgery, Advanced Endovascular Aortic Research Program, Mayo Clinic, Rochester, Minn
| | - Tilo Kölbel
- Department of Vascular Medicine, German Aortic Center, University Heart & Vascular Center Hamburg, Hamburg, Germany
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Harky A, Ahmad MU, Santoro G, Eriksen P, Chaplin G, Theologou T. Local Versus General Anesthesia in Nonemergency Endovascular Abdominal Aortic Aneurysm Repair: A Systematic Review and Meta-Analysis. J Cardiothorac Vasc Anesth 2020; 34:1051-1059. [DOI: 10.1053/j.jvca.2019.07.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 06/09/2019] [Accepted: 07/02/2019] [Indexed: 01/14/2023]
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Regional anesthesia for vascular surgery: does the anesthetic choice influence outcome? Curr Opin Anaesthesiol 2020; 32:690-696. [PMID: 31415047 DOI: 10.1097/aco.0000000000000781] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Outcomes following surgery are of major importance to clinicians, institutions and most importantly patients. This review examines whether regional anesthesia and analgesia influence outcome after vascular surgery. RECENT FINDINGS Large database analyses of contemporary practice suggest that utilizing regional anesthesia for both open and endovascular aortic aneurysm repair, lower limb revascularization and carotid endarterectomy reduces morbidity, length of stay and possibly even mortality. Results from such analyses are limited by an inherent risk of bias but are nevertheless important given the number of patients required in randomized trials to detect differences in rare outcomes. There is minimal evidence that regional anesthesia influences longer term outcomes except for arteriovenous fistula surgery where brachial plexus blocks appear to improve 3-month fistula patency. SUMMARY Patients undergoing vascular surgery often have multiple comorbidities and it is important to be able to outline both benefits and risks of regional anesthesia techniques. Regional anesthesia in vascular surgery allows avoidance of general anesthesia and does provide short-term benefits beyond superior analgesia. Evidence of long-term benefits is lacking in most procedures. Further work is required on newer patient centered outcomes.
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Michaels JA. Are NICE processes fit for the evaluation of new interventional procedures? Br J Surg 2019; 106:1719-1722. [PMID: 31747068 DOI: 10.1002/bjs.11261] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 05/13/2019] [Indexed: 11/07/2022]
Affiliation(s)
- J A Michaels
- School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent Street,, Sheffield, S1 4DA, UK
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Abdul Jabbar A, Chanda A, White CJ, Jenkins JS. Percutaneous endovascular abdominal aneurysm repair: State‐of‐the art. Catheter Cardiovasc Interv 2019; 95:767-782. [DOI: 10.1002/ccd.28576] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Revised: 08/27/2019] [Accepted: 10/25/2019] [Indexed: 12/17/2022]
Affiliation(s)
- Ali Abdul Jabbar
- Interventional CardiologyOchsner Clinic Foundation New Orleans Louisiana
| | - Arijit Chanda
- Interventional CardiologyOchsner Clinic Foundation New Orleans Louisiana
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Uberoi R, Jenkins M. Is This the End for EVAR? Cardiovasc Intervent Radiol 2019; 43:169-171. [DOI: 10.1007/s00270-019-02361-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 10/17/2019] [Indexed: 10/25/2022]
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Dawkins C, Hollingsworth AC, Walker P, Milburn S, Danjoux G, Cheesman M, Mofidi R. Anaerobic threshold as an independent predictor of mid-term survival following elective endovascular repair of abdominal aortic aneurysm. THE JOURNAL OF CARDIOVASCULAR SURGERY 2019; 61:596-603. [PMID: 31599146 DOI: 10.23736/s0021-9509.19.11052-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The aim of this study was to examine the value preoperative AT as predictor of postoperative survival in patients who underwent elective EVAR for repair of asymptomatic AAA. METHODS Consecutive patients who underwent elective EVAR between 2008 and 2018 were analyzed. Cardiopulmonary exercise testing was performed. Perioperative 30-day mortality was compared between patients who had AT ≥8 mL/kg/min and those with AT<8 mL/kg/min. Risk factors for postoperative survival following EVAR were examined using Cox's regression analysis. RESULTS Between 1<sup>st</sup> January 2008 and 31<sup>st</sup> December 2017, 430 patients underwent elective EVAR (standard device: N.=374, fenestrated/branched: N.=56); their median age was 76 years (range: 53-91 years), median AT was 9.3 (range: 5.4-16.1), and 30-day mortality was 0.9%. These patients were followed up for a median of 1630 days. There was no significant difference in perioperative 30-day mortality between patients who had AT≥8 and those who had AT<8 (χ<sup>2</sup>=1.56, P=0.22). Age (HR=1.51 [CI: 1.07-1.99], P<0.05) and AT (HR=0.59 [CI: 0.45-0.76], P=0.0003) were predictors of reduced postoperative survival following elective EVAR whereas gender (HR=0.75 [CI: 0.4-1.4], P=0.37), AAA diameter (HR=0.95 [CI: 0.77-1.16], P=0.6), and AAA morphology (HR=1.23 [CI: 0.68-1.76], P=0.95) were not. CONCLUSIONS Anaerobic threshold is an independent predictor of prolonged survival following elective EVAR and can be used to identify patients who receive most benefit from elective EVAR.
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Affiliation(s)
- Claire Dawkins
- Department of Vascular Surgery, James Cook University Hospital, Middlesbrough, UK
| | | | - Paul Walker
- Department of Interventional Radiology, James Cook University Hospital, Middlesbrough, UK
| | - Simon Milburn
- Department of Interventional Radiology, James Cook University Hospital, Middlesbrough, UK
| | - Gerard Danjoux
- Department of Anesthesia, James Cook University Hospital, Middlesbrough, UK
| | - Matthew Cheesman
- Department of Anesthesia, James Cook University Hospital, Middlesbrough, UK
| | - Reza Mofidi
- Department of Vascular Surgery, James Cook University Hospital, Middlesbrough, UK -
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Kalender G, Lisy M, Stock UA, Endisch A, Kornberger A. Long-term radiation exposure in patients undergoing EVAR: Reflecting clinical day-to-day practice to assess realistic radiation burden. Clin Hemorheol Microcirc 2019; 71:451-461. [PMID: 30248048 DOI: 10.3233/ch-170344] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Endovascular repair of aortic aneurysms (EVAR) has become an established treatment option currently applied in an increasing numbers of patients with aortic aneurysms. Advantages include reduced surgical trauma, procedural time, intensive care unit and hospital lengths of stay, blood loss as well as morbidity and mortality.The optimal imaging modalities in EVAR follow-up as well as the appropriate intervals between these follow-ups remain subject of controversial discussion. Objective of this study was the evaluation of the realistic radiation exposure and risk estimate postop EVAR treatment.Of the follow-ups required according to the surveillance schedule during the first year post-EVAR, only 68.3% were actually implemented. Of those required from the second year onwards, an average of 70% was actually performed. During the observation period, each patient underwent a mean of 4.3 CTAs. The median ED calculated from all CTAs was 24. 5 mSv. The minimum and maximum cumulative EDs for the entire observation period were 55 mSv and 310 mSv, respectively.
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Affiliation(s)
- G Kalender
- Department of Vascular and Endovascular Surgery, DRK Hospital Berlin Köpenick, Berlin, Germany
| | - M Lisy
- Department of Vascular and Endovascular Surgery, Krankenhaus Nordwest Frankfurt, Germany
| | - U A Stock
- Department of Cardiac and Transplant Surgery, Royal Brompton and Harefield NHS Trust, Harefield, UK
| | - A Endisch
- Department of Vascular and Endovascular Surgery, Asklepios Hospital Bad Tölz, Germany
| | - A Kornberger
- Department of Vascular, Thoracic and Cardiovascular Surgery, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Germany
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Optimizing Surveillance and Re-intervention Strategy Following Elective Endovascular Repair of Abdominal Aortic Aneurysms. Ann Surg 2019; 274:e589-e598. [PMID: 31592810 DOI: 10.1097/sla.0000000000003625] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND EVAR for abdominal aortic aneurysm has an initial survival advantage over OR, but more frequent complications increase costs and long-term aneurysm-related mortality. Randomized controlled trials of EVAR versus OR have shown EVAR is not cost-effective over a patient's lifetime. However, in the EVAR-1 trial, postoperative surveillance may have been sub-optimal, as the importance of sac growth as a predictor of graft failure was overlooked. METHODS Real-world data informed a discrete event simulation model of postoperative outcomes following EVAR. Outcomes observed EVAR-1 were compared with those from 5 alternative postoperative surveillance and re-intervention strategies. Key events, quality-adjusted life years and costs were predicted. The impact of using complication and rupture rates from more recent devices, imaging and re-intervention methods was also explored. RESULTS Compared with observed EVAR-1 outcomes, modeling full adherence to the EVAR-1 scan protocol reduced abdominal aortic aneurysm (AAA) deaths by 3% and increased elective re-interventions by 44%. European Society re-intervention guidelines provided the most clinically effective strategy, with an 8% reduction in AAA deaths, but a 52% increase in elective re-interventions. The cheapest and most cost-effective strategy used lifetime annual ultrasound in primary care with confirmatory computed tomography if necessary, and reduced AAA-related deaths by 5%. Using contemporary rates for complications and rupture did not alter these conclusions. CONCLUSIONS All alternative strategies improved clinical benefits compared with the EVAR-1 trial. Further work is needed regarding the cost and accuracy of primary care ultrasound, and the potential impact of these strategies in the comparison with OR.
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Zoethout AC, Zerwes S, Zeebregts CJ, Heyligers JM, De Vries JPJ, Oberhuber A, Karl T, Berg P, Stenson K, Loftus I, Torella F, Szopiński P, Zimmermann E, Holden A, Hyhlik-Duerr A, Reijnen MM. Preliminary outcome of Nellix-in-Nellix extensions in patients treated with failed endovascular aneurysm sealing. J Vasc Surg 2019; 70:1099-1106. [DOI: 10.1016/j.jvs.2019.01.044] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Accepted: 01/01/2019] [Indexed: 11/25/2022]
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Krajcer Z, Ramaiah VG, Henao EA, Nelson WK, Moursi MM, Rajasinghe HA, Anderson LH, Miller LE. Comparison of perioperative costs with fast-track vs standard endovascular aneurysm repair. Vasc Health Risk Manag 2019; 15:385-393. [PMID: 31564888 PMCID: PMC6731968 DOI: 10.2147/vhrm.s210593] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Accepted: 08/17/2019] [Indexed: 11/23/2022] Open
Abstract
Background Perioperative health care utilization and costs in patients undergoing elective fast-track vs standard endovascular aneurysm repair (EVAR) remain unclear. Methods The fast-track EVAR group included patients treated with a 14 Fr stent graft, bilateral percutaneous access, no general anesthesia or intensive care monitoring, and next-day hospital discharge. The standard EVAR group was identified from Medicare administrative claims using a matching algorithm to adjust for imbalances in patient characteristics. Hospital outcomes included operating room time, intensive care monitoring, hospital stay, secondary interventions, and major adverse events (MAEs). Perioperative outcomes occurring from hospital discharge to 30 days postdischarge included MAE, secondary interventions, and unrelated readmissions. Results Among 1000 matched patients (250 fast-track; 750 standard), hospital outcomes favored the fast-track EVAR group, including shorter operating room time (2.30 vs 2.83 hrs, P<0.001), shorter hospital stay (1.16 vs 1.69 d, P<0.001), less need for intensive care monitoring (4.4% vs 48.0%, P<0.001), and lower secondary intervention rate (0% vs 2.4%, P=0.01). Postdischarge outcomes also favored fast-track EVAR with a lower rate of MAE (0% vs 7.2%, P<0.001) and all-cause readmission (1.6% vs 6.8%, P=0.001). The total cost to the health care system during the perioperative period was $26,730 with fast-track EVAR vs $30,730 with standard EVAR. Total perioperative health care costs were $4000 (95% CI: $3130–$4830) lower with fast-track EVAR vs standard EVAR, with $2980 in savings to hospitals and $1030 savings to health care payers. Conclusion A fast-track EVAR protocol using a 14 Fr stent graft resulted in shorter procedure time, lower intensive care utilization, faster discharge, lower incidence of MAE, lower readmission rates, and lower perioperative costs compared to standard EVAR.
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Affiliation(s)
- Zvonimir Krajcer
- Department of Cardiology, CHI St. Luke's Health, Houston, TX, USA
| | | | - Esteban A Henao
- Department of Vascular Surgery, Heart Hospital of New Mexico, Albuquerque, NM, USA
| | - Wayne K Nelson
- Department of Vascular Surgery, St. Charles Hospital, Bend, OR, USA
| | - Mohammed M Moursi
- Department of Vascular Surgery, Central Arkansas Veterans Healthcare System, Little Rock, AR, USA
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Affiliation(s)
- Ruth Benson
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Gordon McGregor
- Centre for Sport, Exercise & Life Sciences, Coventry University, Coventry, UK
| | - Mishkat Shehata
- Unit of Academic Primary Care, University of Warwick, Coventry, UK
| | - Christopher Imray
- Warwick Medical School, Coventry University and Exeter University, UK
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Canning P, Tawfick W, Whelan N, Hynes N, Sultan S. Cost-effectiveness analysis of endovascular versus open repair of abdominal aortic aneurysm in a high-volume center. J Vasc Surg 2019; 70:485-496. [DOI: 10.1016/j.jvs.2018.11.018] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 11/05/2018] [Indexed: 12/20/2022]
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