To what extent has endovascular aneurysm repair influenced abdominal aortic aneurysm management in the state of Illinois?

PURPOSE: This study was performed using population-based data to determine the changing trends in the techniques for abdominal aortic aneurysm (AAA) repair in the state of Illinois during the past 9 years and to examine the extent to which endovascular aneurysm repair (EVAR) has influenced overall AAA management. METHODS: All records of patients who underwent AAA repair (1995 to 2003 inclusive) were retrieved from the Illinois Hospital Association COMPdata database. The outcome as determined by in-hospital mortality was analyzed according to intervention type (open vs EVAR) and indication (elective repair vs ruptured AAA). Data were stratified by age, gender, and hospital type (university vs community setting) and then analyzed using both univariate (chi 2 , t tests) and multivariate (stepwise logistic regression) techniques. RESULTS: Between 1995 and 2003, 14,517 patients underwent AAA repair (85% for elective and 15% for ruptured AAA). The average age was 71.4 +/- 7.9 years, and 76% were men. For elective cases, open repair was performed in 86% and EVAR in 14%; and for ruptured cases, open repair in 97% and EVAR in 3%. Elective EVAR was associated with lower in-hospital mortality compared with open repair regardless of age. No differences were observed with age after either type of repair for a ruptured aneurysm. Men had a lower in-hospital mortality compared with women for open repair of both elective and ruptured aneurysms. For EVAR, the mortality of an elective repair was lower in men, but there was no difference after a ruptured AAA. In men, the difference in mortality between elective open repair and EVAR was significant; the type of institution did not influence outcome. Patients >80 years of age had a higher mortality after open repair for both elective and ruptured AAA and after EVAR of a ruptured AAA. The average length of stay was 9.9 days for open elective repair, 13.1 days after open repair of a ruptured AAA, and 3.6 days for EVAR. The independent predictors of higher in-hospital mortality were female gender, age >80 years, diagnosis (ruptured vs open), and procedure (open vs EVAR). The year of the procedure and type of hospital (university vs community) were not predictive of outcome. CONCLUSIONS: EVAR has had a significant impact on AAA management in Illinois over a relatively short time period. In this population-based review, EVAR was associated with a significantly decreased in-hospital mortality and length of stay. Octogenarians had higher mortality after both types of repair, with the exception of elective EVAR.     

Outcome and Quality of Life in Patients Treated for Abdominal Aortic Aneurysms: A Single Center Experience

BACKGROUND: Durability of protection and long-term quality of life (QoL) are critical outcome parameters of abdominal aortic aneurysm (AAA) repair. The aim of the present study was to compare results of endovascular and open aneurysm repair (EVAR and OR) with adjusted standard populations, including stratification for urgency of presentation. METHODS: Retrospective analysis of prospectively collected data of 401 consecutive patients presenting with AAA between January 1998 and December 2002. Cross-sectional follow up was 58 +/- 29 months. Patients were grouped into three cohorts: elective EVAR (n = 68), elective OR (n = 244), and emergency OR (including symptomatic and ruptured AAA, n = 89). Endpoints were perioperative (i.e., 30 days or in-hospital) and late mortality rates, as well as long-term QoL as assessed by the Short Form health survey questionnaire (SF-36). RESULTS: Mean age was lower in the elective OR cohort (66 +/- 10 years) than in the EVAR cohort (72 +/- 7 years; p < .05). Perioperative mortality rates were 4.4%, 0.4%, and 10.1%, for the EVAR, elective OR, and emergency OR cohorts, respectively (p < .05). Corresponding cumulative survival rates after 4 years were 67%, 89%, and 69%, respectively. Long-term QoL SF-36 scores were in all cohorts similar to age- and gender-adjusted standard populations, which score between 85 and 115: 99.6 +/- 35.8 (EVAR), 101.3 +/- 32.4 (elective OR), and 100.4 +/- 36.5 (emergency OR). CONCLUSIONS: Long-term QoL is not permanently impaired after AAA repair, but returns in long-term survivors to what would be expected in a standard population. In this respect, differences were found neither between EVAR and OR, nor between elective and emergency repair. Perioperative mortality rates were highest in patients undergoing emergency OR. The outlook for such patients after the perioperative period, however, was similar to that for patients undergoing elective repair.     

Abdominal aortic aneurysm repair in octogenarians: myth or reality?

AIM: We studied the thirty-day mortality and morbidity rate to assess the value of conventional open repair vs endovascular aortic repair (EVAR) in an elderly population presenting with a ruptured, symptomatic or asymptomatic abdominal aortic aneurysm (AAA) undergoing emergency, urgent or elective repair. METHODS: During the period from January 2004 to May 2007, 329 consecutive patients were treated for AAA in our Department. Among these, 81 (24.6%) were aged >80 years (mean age 83.6, range 80-95 years). These older patients were divided into groups according to their clinical presentation: ruptured AAA group (rAAA) - 22 cases (4 emergency EVAR, 18 emergency open repair); symptomatic non-ruptured AAA group (sAAA) - 15 cases (11 urgent EVAR, 4 urgent open repair); asymptomatic AAA group (asAAA) - 44 cases (32 elective EVAR, 12 elective open repair). The main outcome measures were 30-day mortality and 30-day morbidity rate. RESULTS: The mortality rate following open surgery vs EVAR was 66.6% vs 50% (P=NS) in the rAAA group, 25% vs 0% (P=NS) in the sAAA group, and 9% vs 3.2% (P=NS) in the asAAA group. When comparing postoperative morbidities in the octogenarians, 3 of the patients that received EVAR (6.4%) and 15 of those that received open repair (48.4%) had a severe complication (P<0.01). CONCLUSION: The introduction of EVAR has considerably changed the balance of risks and benefits for AAA treatment. Our study confirms the high mortality rate for octogenarians with rAAA and haemodynamic instability, and supports the value of an active EVAR approach for octogenarians with AAA to prevent rupture. Moreover, the introduction of endovascular techniques as part of an overall treatment algorithm for ruptured AAAs appears to be potentially associated with improved outcomes in terms of mortality and morbidity as compared to open surgical repairs alone.     

Long-term outcomes comparing endovascular and open abdominal aortic aneurysm repair in octogenarians

ObjectivePatients older than 80 years have significantly lower early mortality with endovascular aneurysm repair (EVAR) compared with open repair for abdominal aortic aneurysms (AAAs), but long-term results remain poorly studied. We analyzed the results of both emergent and elective AAA repair in patients aged 80 years or older who had at least 5 years of follow-up.MethodsRetrospective review of a prospectively collected vascular surgery database was performed to identify all patients who underwent elective repair of an AAA between 2007 and 2012 and were 80 years of age or older at the time of surgery. Open and EVAR groups were compared using univariate statistics.ResultsThe study cohort was composed of 314 patients 80 years of age or older (median, 83 years; interquartile range, 5 years) who underwent repair (96 open, 218 EVAR). The groups had similar comorbidities, except that EVAR patients were more likely to be male and open repair patients were more likely to have larger aneurysms. Compared with open repair, elective early postoperative mortality was significantly lower for EVAR patients (1% vs 14%; P < .001). Overall mean life expectancy was 5.9 years (EVAR, 5.8 years; open repair, 5.8 years; P = .98). The 1-year survival was significantly higher for EVAR (92.9%) than for open repair (84.1%; P = .02). The 2-year survival (EVAR, 83.4%; open repair, 74.6%; P = .07) and 5-year survival (EVAR, 57.8%; open repair, 60.3%; P = .98) did not differ between EVAR and open repair. Reintervention rates (EVAR, 18%; open repair, 2%; P = .05) were higher in the endovascular treatment group.ConclusionsEVAR results in an improved 1-year mortality in octogenarians compared with open repair, although 5-year survival is similar between the groups. With average life expectancies of >5 years and an 18% reintervention rate, diligent follow-up is required after EVAR even in elderly patients.     

Late survival after elective repair of aortic aneurysms detected by screening.

BACKGROUND: The aim of this study was to examine whether there was any survival advantage in men following elective repair of an abdominal aortic aneurysm (AAA) detected by ultrasound screening compared to those with an AAA detected incidentally. METHODS: A total of 424 men underwent elective AAA repair between 1990 and 1998; 181 were detected in an aneurysm screening programme and 243 were diagnosed incidentally. Follow-up survival data were collected until 2003 (minimum 5 years) and survival curves were compared using regression analysis. RESULTS: The postoperative 30-day mortality rate was significantly lower in men whose aneurysms were detected by screening (4.4%), compared with those detected incidentally (9.0%). Similarly, 5-year survival (78% vs. 65%) and 10-year survival rates (63% vs. 40%) were better after repair of a screen-detected AAA (p<0.0003 at all time intervals, by log rank testing). Multivariate analysis showed that this was largely due to the older age of men who had repair of an incidental AAA (71.2 vs. 67.1 years). CONCLUSION: Men who had elective repair of an AAA detected by screening had a better late survival rate than men whose aneurysm was discovered incidentally because they were younger at the time of surgery.     

Outcomes of hemodialysis-dependent patients following elective abdominal aortic aneurysm repair

As hemodialysis-dependent patients have a shorter life expectancy it has been recently questioned whether they benefit from procedures such as abdominal aortic aneurysm (AAA) repair. The purpose of this study was to review our results with elective AAA repair in hemodialysis-dependent patients. During a recent 6-year period (1998-2003), 7 such patients underwent elective repair of their infrarenal aortic aneurysms. Mean age and aneurysm diameter were 71 years and 69 mm, respectively. Mean length of stay was 28.6 days including routine intensive care unit admission. Three patients underwent standard open repair, and 3 underwent endovascular repair. In the seventh patient iliac calcification precluded endograft delivery and resulted in conversion to open repair. Another endovascular patient suffered from perforation of her sigmoid colon. One- and 3-year survival rates in the entire cohort were 100% and 75%, respectively. The authors conclude that aneurysm repair in hemodialysis patients is warranted and life prolonging in appropriate risk patients, despite lengthy hospital stays. However, successful endovascular repair may be prevented by the severe arterial calcification in these patients.     

Blood loss and transfusion in elective abdominal aortic aneurysm surgery

BACKGROUND: Intraoperative blood loss and transfusion are known determinants of mortality and morbidity of elective abdominal aortic aneurysm (AAA) repair. The present study analysed the pattern of blood loss and transfusion and evaluated the risk factors of blood loss during open repair of infrarenal AAA. METHODS: Blood loss, transfusion and fluid replacement during elective open repair operation for patients with infrarenal AAA were correlated to demographic data, operative findings and procedural information. RESULTS: A total of 129 patients with a mean age of 71 years was analysed. The mean blood loss was 1000 +/- 887 mL (200-6000 mL). Blood transfusion, with a mean transfusion volume of 400 +/- 591 mL (0-3000 mL), was required in 46% of patients. Univariate analysis showed that bodyweight, renal impairment, low haemoglobin and platelet counts, iliac artery involvement, large aneurysm, bifurcated graft, large graft diameter, prolonged aortic clamp time and long operation time were associated with a higher blood loss. A haemoglobin level of <10.5 g/dL (relative risk (RR): 4.6), platelet count <130 x 10(9)/L (RR: 3.9), aortic clamp time >50 min (RR: 15), total operation time >200 min (RR: 11) and type of graft (RR: 3.5) were identified as independent determinants of blood loss on multivariate analysis. CONCLUSION: Intraoperative blood loss in elective infrarenal aneurysm surgery is influenced by patients' haematological parameters, distal involvement of aneurysm and degree of difficulty of operation.     

A personal experience with factors influencing survival after elective open repair of infrarenal aortic aneurysms

OBJECTIVE: To investigate risk factors that influence survival after open abdominal aortic aneurysm (AAA) repair in all elective patients treated by a single surgeon at a tertiary referral center. METHODS: The series includes 855 asymptomatic infrarenal AAAs in 732 men (86%) and 123 women with median ages of 69 and 71 years, respectively. Noninvasive myocardial imaging (n = 325), coronary arteriography (n = 418), or both were performed before surgery in 687 patients (80%), and 100 patients (15%) underwent preliminary coronary artery bypass grafting (n = 78) or percutaneous transluminal coronary angioplasty (n = 22) before their AAA procedures. Survival was assessed by using logistic regression analysis, proportional hazards models, and Kaplan-Meier estimations. RESULTS: The operative mortality rate was 2.5%, ranging only from 1.8% to 2.8% since 1980. Late survival rates (70% at 5 years, 36% at 10 years, and 16% at 15 years) also remained remarkably similar during five arbitrary intervals comprising the entire study period. On multivariable analysis, overall mortality rates were adversely affected by older age (P < .001), increased creatinine levels (P < .001), straight aortic replacement grafting (P < .001), larger aneurysm diameter (P = .036), and chronic obstructive pulmonary disease (P = .012). The risk for any early or late death was favorably influenced by preliminary coronary artery bypass grafting or percutaneous transluminal coronary angioplasty (hazard ratio, 0.76; 95% confidence interval, 0.59-0.98; P = .035) even when a separate multivariable model was fit to accommodate nine other patients who also had preliminary coronary intervention but developed symptomatic AAAs before elective repair could be performed (hazard ratio, 0.78; 95% confidence interval, 0.61-0.99; P = .044). CONCLUSIONS: Patient age and medical risk factors determine survival after open AAA repair to a very similar degree irrespective of the era when the operation is performed. In this particular series, preliminary coronary intervention seemed to benefit patients with severe coronary artery disease.     

Should endovascular surgery lower the threshold for repair of abdominal aortic aneurysms?

PURPOSE: Because endovascular repair of abdominal aortic aneurysms (AAAs) is less invasive, some investigators have suggested that this increasingly popular technique should broaden the indications for elective AAA repair. The purpose of this study was to calculate quality-adjusted life expectancy rates after endovascular and open AAA repair and to estimate the optimal diameter for elective AAA repair in hypothetical cohorts of patients at average risk and at high risk. METHODS: A Markov decision analysis model was used in this study. Assumptions were made on the basis of published reports and included the following: (1) the annual rupture rate is a continuous function of the AAA diameter (0% for <4 cm, 1% for 4.5 cm, 11% for 5.5 cm, and 26% for 6.5 cm); (2) the operative mortality rate is 1% for endovascular repair (excluding the risk of conversion to open repair) and 3.5% for open repair at age 70 years; and (3) immediate endovascular-to-open conversion risk is 5%, and late conversion rate is 1% per year. The main outcome measure in this study was the benefit of AAA repair in quality-adjusted life years (QALYs). The optimal threshold size (the AAA diameter at which elective repair maximizes benefit) was measured in centimeters. RESULTS: The benefit of endovascular repair is consistently greater than that of open repair, but the additional benefit is small-0.1 to 0.4 QALYs. For men in average health with gradually enlarging AAAs with initial diameters of 4 cm, endovascular surgery reduces the optimal threshold diameter by very little: from 4.6 to 4.6 cm (no change) at age 60 years, from 4.8 to 4.7 cm at age 70 years, and from 5.1 to 4.9 cm at age 80 years. For older men in poor health, endovascular surgery reduces the optimal threshold diameter substantially (8.1 to 5.7 cm at age 80 years), but the benefit of repair in this population is small (0.2 QALYs). CONCLUSION: For most patients, the indications for AAA repair are changed very little by the introduction of endovascular surgery. Only for older patients in poor health does endovascular surgery substantially lower the optimal threshold diameter for elective AAA repair.     

Elective abdominal aortic aneurysm repair: does the aneurysm diameter influence long-term survival?

OBJECTIVES: The aim of this study was to investigate whether initial abdominal aortic aneurysm (AAA) diameter influences long-term survival after elective repair. DESIGN: Retrospective analysis of database. MATERIAL AND METHODS: Between March 1995 and December 2006, a consecutive series of 895 patients underwent elective treatment of an AAA either by open surgical or endovascular repair. An AAA diameter of 5.5cm was chosen as threshold to distinguish between small and large aneurysms, according to the definition given by the UK small aneurysm trial. Patient characteristics and distribution of basic risk factors were assessed. Survival estimates (Kaplan-Meier) and Cox proportional hazards regression results are reported. RESULTS: Patients with small aneurysms were more likely to survive the first 6 years after AAA repair, even after adjustment for treatment modality and baseline risk factors. After adjustment for age and sex aneurysms with smaller diameter were related to a lower risk of death (p<0.0016). CONCLUSIONS: Patients with small aneurysms (< or =5.5cm) have an improved long-term survival than patients with larger aneurysms.     

TREATMENT OF ABDOMINAL AORTIC ANEURYSM DISEASE IN THE 9TH AND 10TH DECADES OF LIFE

Background : The appropriate management of patients who are older than 80 years of age and who present with an abdominal aortic aneurysm (AAA) remains controversial. While it appears that elective repair can be performed safely, appropriate management of these patients in the emergency situation is unclear. The purpose of the present study was to examine the results obtained in treating this elderly group in the elective and emergency setting, by operation and conservative techniques at St George Hospital, Kogarah. Methods : Between January 1987 and December 1994 85 patients older than 80 years of age were treated for AAA. These patients were divided into four groups: I, elective presentatiodno surgery; II, elective presentatiodelective surgical repair; III, emergency presentatiodsurgical repair; and IV, emergency presentatiodconservative treatment. We examined age, sex, size of AAA, mode of presentation, type of treatment, length of survival and cause of death. Results : The mean age of the total group (n = 85) of patients was 84 years (range: 80–94). The mean AAA diameter for this group was 5.6 cm (95% CI: 5.2–6 cm). The diameters for group I (n= 40), II (n= 22), III (n= 16) and IV (n = 7) were 4.9 cm (4.4–5.5, 95% CI), 5.7 (4.9–6.5 CI), 7.0 (6.1–7.7 CI) and 6.2 (5.2–7.2 CI), respectively. The median survival for groups I, II, III and IV was 18, 38.5, 0.25 and 0 months, respectively. Group II had a longer survival than any other group (P= 0.015). and group IV had a shorter survival than the total group (P= 0,001). However, the length of survival was no different for III versus IV (P= 0.146). Deaths in each group were due to the following reasons. I: cardiopulmonary events (14), rupture (3), malignancy/sepsis (3); II: cardiopulmonary events (3), rupture (thoracic aneurysm) (2). malignancy (1); III: rupture (10), malignancy (1); and (IV): rupture (6), malignancy (1). Conclusions : Elective surgical repair offers the best management option for AAA in patients older than 80 years of age. Death may still occur from progression of aneurysmal disease at other sites. An aggressive surgical approach to the management of haemodynamically unstable patients in this age group is of questionable benefit.     

Endovascular ruptured abdominal aortic aneurysm repair – setting up your hospital for an endovascular approach

In recent years, major improvements have been made, making elective repair of abdominal aortic aneurysm (AAA) a safe procedure. In selected series, mortality rates are less than 5%. Many of the patients with AAA, however, remain asymptomatic until they present with rupture. Once rupture has occurred, the overall mortality approaches 90%. Despite many advances in the management of ruptured AAA, the mortality rate of conventional open surgery has not improved significantly during the last 15 years. Over the last decade, endovascular techniques have been used increasingly to repair AAA, and there is increasing evidence that endovascular aneurysm repair (EVAR) is technically feasible and safe for ruptured AAA. This review studies the evidence and aids the clinician in setting up a practice to manage rAAAs utilizing an endovascular approach.     

Comparative early and midterm results of open juxtarenal and infrarenal aneurysm repair

Background and aims Since the introduction of endovascular aortic aneurysm repair (EVAR) for aortic aneurysms, the number of juxtarenal aortic aneurysms (JRA) has been growing steadily due to selection bias (neck morphology for EVAR). This case-match study compares the perioperative outcome and midterm results of suprarenally clamped JRA with infrarenal aortic aneurysms (AAA). Methods From 1997 to 2004, patients who received open surgery with suprarenal clamping for JRA were included in the study and compared to matched patients with infrarenal clamping (AAA). Measurements analyzed were the in-hospital mortality and morbidity. Midterm results were obtained through clinical investigation and magnetic resonance angiography imaging. Results Thirty-five patients (mean age, 68.4 years; 30 male and 5 female) received suprarenal cross-clamping for JRA. The overall in-hospital mortality for JRA and for the controls (AAA) with elective aortic repair was 4.5% (6.1% JRA; 3% AAA, p = 0.058). The morbidity of JRA was elevated according to the rate of pulmonary complications (p = 0.021) and the need for re-operation (p = 0.019). The mean follow-up time was 2.3 years (range, 8–96 months). At follow-up, 28 patients (80%) from the JRA group and 29 patients from the AAA group (82.9%) were alive. Conclusion Open aortic surgery for JRA with the need for suprarenal cross-clamping shows a slightly elevated in-hospital mortality rate without statistical significance and equal midterm mortality results in comparison with infrarenally clamped aortic aneurysms.     

Abdominal aortic aneurysm rupture rates: A 7-year follow-up of the entire abdominal aortic aneurysm population detected by screening

Purpose: The goal of the current study was to identify the risk of rupture in the entire abdominal aortic aneurysm (AAA) population detected through screening and to review strategies for surgical intervention in light of this information. Methods: Two hundred eighteen AAAs were detected through ultrasound screening of a family practice population of 5394 men and women aged 65 to 80 years. Subjects with an AAA of less than 6.0 cm in diameter were followed prospectively with the use of ultrasound, according to our protocol, for 7 years. Patients were offered surgery if symptomatic, if the aneurysm expanded more than 1.0 cm per year, or if aortic diameter reached 6.0 cm. Results: The maximum potential rupture rate (actual rupture rate plus elective surgery rate) for small AAAs (3.0 to 4.4 cm) was 2.1% per year, which is less than most reported operative mortality rates. The equivalent rate for aneurysms of 4.5 to 5.9 cm was 10.2% per year. The actual rupture rate for aneurysms up to 5.9 cm using our criteria for surgery was 0.8% per year Conclusion: In centers with an operative mortality rate of greater than 2%, (1) surgical intervention is not indicated for asymptomatic AAAs of less than 4.5 cm in diameter, and (2) elective surgery should be considered only for patients with aneurysms between 4.5 and 6 cm in diameter that are expanding by more than 1 cm per year or for patients in whom symptoms develop. In centers with elective mortality rates of greater than 10% for abdominal aortic aneurysm (AAA) repair, the benefit to the patient of any surgical intervention for an asymptomatic AAA of less than 6.0 cm in diameter is questionable. (J Vasc Surg 1998;28:124-8.)     

Oxygen-dependent chronic obstructive pulmonary disease does not prohibit aortic aneurysm repair.

BACKGROUND: Severe oxygen-dependent chronic obstructive pulmonary disease (COPD) is considered by many to be a contraindication to open abdominal aortic aneurysm (AAA) repair. We reviewed our own experience with this patient population. METHODS: From July 1995 to March 1999, 14 consecutive patients limited by home oxygen-dependent COPD underwent elective open infrarenal AAA repair. Their medical records were reviewed. RESULTS: The mean aortic aneurysm size was 6.3 cm. The mean PaO2 = 70 mm Hg, PaCO2 = 45 mm Hg, forced expiratory volume in 1 second (FEV1) = 34% of predicted, and forced vital capacity (FVC) = 67% of predicted. All 14 patients were extubated within 24 hours, mean length of hospital stay was 5.9 days, and there were no perioperative deaths. CONCLUSIONS: Severe home oxygen-dependent COPD is not a contraindication to safe elective open AAA repair.     

Analysis of medical risk factors and outcomes in patients undergoing open versus endovascular abdominal aortic aneurysm repair

OBJECTIVE: The emergence of endovascular repair (ER) for infrarenal abdominal aortic aneurysm (AAA) has provided surgeons with a new technique that should ideally improve patient outcomes. To more accurately characterize the advantages of ER versus traditional/open AAA repair (TOR), we compared the preoperative medical risk factors (PMRFs) and perioperative outcomes (PO) of those patients undergoing elective treatment of infrarenal AAA with ER and TOR over a recent 18-month period at our center. METHODS: Through our institutional vascular surgery patient registry, all patients undergoing aortic aneurysm repair of any type between December 1999 and June 2001 were identified. Only those patients undergoing elective infrarenal AAA repair were analyzed. Hospital records were examined for all patients, and PMRF and PO were assessed via Society for Vascular Surgery/International Society for Cardiovascular Surgery reporting guidelines. Student t, chi(2), Fisher exact, or Wilcoxon rank sum tests were applied where appropriate to determine differences among PMRF and PO according to method of aneurysm repair. RESULTS: During the 18-month study period, a total of 199 aortic aneurysms were repaired at our institution. Ninety-nine elective infrarenal AAA repairs made up the study cohort (ER, n = 33; TOR, n = 66). When examined by method of aneurysm repair, no differences existed in demographics or AAA size. Patients undergoing ER had a significantly greater degree of preoperative pulmonary comorbidity than patients undergoing TOR (P <.001). However, no differences existed in terms of American Society of Anesthesiologists classification or cardiac (P =.52), cerebrovascular (P =.44), diabetic (P =.51), hypertensive (P =.90), hyperlipidemia (P =.91) or renal (P =.23) comorbidities between the two groups. Perioperative morbidity and mortality rates were also not significantly different by method of repair. ER was associated with shorter operative time, intensive care unit stay, and overall hospital length of stay (P <.0001). However, subsequent operative procedures related to the AAA repair were performed more frequently after ER (TOR = 1.5% versus ER = 15.2%; P = 0.015). CONCLUSION: These results suggest that ER offers improvements in hospital convalescent and operating room times but no beneficial impact on overall morbidity and mortality rates when similar PMRFs exist, especially when used at medical centers where low morbidity and mortality rates are already established for TOR. Other centers performing ER should undertake such an analysis to assess its impact on their patients.     

Abdominal aortic aneurysm repair in the over eighties

Between January 1980 and September 1988, 34 octogenarians underwent aortic aneurysm repair. There were 26 men and eight women with a median age of 83 years (range 80-88 years). Twenty underwent 'emergency' repair after presenting with pain and/or collapse: 11 with a retroperitoneal rupture, three with an intraperitoneal rupture and six with an expanding aneurysm. The mortality rate for this group was 35 per cent. During the same period 14 patients had an elective repair and there were no deaths within 30 days. The mean hospital stay for the elective group was 14.2 days compared with 17.0 days for survivors in the emergency group. There was no significant difference in terms of risk factors between those who developed postoperative complications and those who did not. These mortality rates compare favourably with our overall mortality results for elective (4.6 per cent) and emergency (31 per cent) surgery. Those patients over 80 years of age with infrarenal abdominal aortic aneurysms should not be refused surgery on the basis of age alone; each patient should be judged individually.     

Physiological comparison of open and endovascular aneurysm repair.

BACKGROUND: This prospective study compared morbidity and mortality rates following conventional and endovascular abdominal aortic aneurysm (AAA) repair using a physiological scoring system. METHODS: Between December 1994 and November 1997, 104 elective open aneurysm repairs and 49 endovascular aneurysm repairs were performed. These patient cohorts were compared using the Portsmouth predictor equation (P-POSSUM) scoring system. Data collected prospectively from patient notes were used to obtain physiological and operative severity scores which were analysed to compare expected and observed mortality and morbidity rates. RESULTS: There were three deaths (6 per cent) in the endovascular AAA repair group and 17 (16 per cent) in the conventional aneurysm repair group, whereas the P-POSSUM formulae predicted mortality rates of 8 and 19 per cent respectively. Although the mean physiological scores were similar for both groups (endovascular 20.8 versus conventional 20.1), the operative severity score was significantly greater in the conventional group (26.3 versus 19.7; P < 0.001). CONCLUSION: In this study open aortic aneurysm repair had a higher operative severity than endovascular repair, which was reflected in the increased mortality rate.     

A decade of change in abdominal aortic aneurysm repair in the United States: Have we improved outcomes equally between men and women?

OBJECTIVES: Abdominal aortic aneurysm (AAA) repair has undergone vast changes in the last decade. We reviewed a national database to evaluate the effect on utilization of services and rupture rates. METHODS: From the Centers for Medicare Services (CMS), a 5% inpatient sample was obtained for 1994 to 2003 as beneficiary encrypted files (5% BEF) and as a limited data set file after 2001. Files were translated into Microsoft Access by using a custom program. Queries were performed using International Classification of Diseases (9th Revision) (ICD-9) diagnosis codes 441.3 (ruptured AAA) or 441.4 (non-ruptured AAA) and ICD-9 procedure codes 38.34, 38.36, 38.44, 38.64, 39.25, 39.52 for open, and 39.71 (available after October 2000) for endovascular repair. The 5% BEF totals were multiplied by 20 to calculate yearly volumes. Total cases were divided into the yearly CMS population of elderly Medicare recipients for repair rates per capita and are reported as cases per 100,000 elderly Medicare recipients. Statistics were performed using chi2, Student's t test, nonparametric tests, and multiple regression analysis; P < or = .05 was considered significant. RESULTS: Elective AAA repairs declined from 94.4/100,000 in 1994 to 87.7/100,000 in 2003. AAA rupture surgery declined from 18.7/100,000 (1994) to 13.6/100,000 (2003). Rupture repairs from 1994 to 2003 decreased by 29% for men and by 12% for women (P < .001). Rupture mortality has not changed, but the average is significantly higher for women at 52.8%, with men averaging 44.2% (P < .001). Mortality for elective AAA repair has decreased from 5.57% (1994) to 3.20% (2003) in men (P < .001) and from 7.48% (1994) to 5.45% (2003) in women (P < .001). Multivariate analysis demonstrated increasing age, female sex, and open surgery (vs endovascular) were significant predictors of elective and ruptured AAA repair mortality. For 2003 elective AAA repairs, the average length of stay was 6.9 days in men and 8.9 days in women (P < .01) For 2003, men were more likely to be discharged to home after rupture (32.9% of men vs 23.3% of women; P < .001) and elective repair (84.5% of men vs 70.1% of women; P < .001). CONCLUSIONS: Improvements in AAA management in the last decade have decreased aneurysm-related deaths and reduced the incidence of aneurysm ruptures, with a lower utilization of services. Women, however, continue to have a consistently higher mortality for open and ruptured AAA repair and are less likely to return to home after either.     

Improving aneurysm-related outcomes: nationwide benefits of endovascular repair

OBJECTIVES: Endovascular aneurysm repair (EVAR) has changed the practice of abdominal aortic aneurysm (AAA) surgery. We examined a national Medicare database to establish the effect of EVAR introduction into the United States. METHODS: A 5% random sample of inpatient Medicare claims from 2000 to 2003 was queried using International Classification of Diseases, 9th Revision (ICD-9) diagnosis and procedure codes. An EVAR procedure code was available after October 2000. Occurrences were multiplied by 20 to estimate yearly national volumes and then divided into the yearly Centers for Medicare and Medicaid Services (CMS) population of elderly Medicare recipients for rates per capita, reported as cases per 100,000 elderly Medicare recipients. Statistical analysis was performed by using chi2, Student's t test, nonparametric tests, and multiple regression analysis, with significance defined as P < or = .05. RESULTS: Elective AAA repairs averaged 87.7 per 100,000 Medicare patients between 2000 and 2003, with EVAR has steadily increasing to 41% of elective repairs in 2003. From 2000 to 2003, overall elective AAA mortality declined from 5.0% to 3.7% (P < .001), while open repair mortality remained unchanged. EVAR patients are significantly older than patients treated with open repair. From 2000 to 2003 patients >84 years receiving EVAR increased to 62.7% (P < .001). Overall hospital length of stay (LOS) decreased from 8.6 days in 2000 to 7.3 days in 2003, P < .001, but increased for open AAA patients. EVAR patients were more likely to be discharged home rather than to skilled facilities. Average elective repair hospital charges were not different between groups, but Medicare reimbursement was lower for EVAR, with a higher proportion cases classified as DRG 111 (major cardiovascular procedure without complications). EVAR was used in 10.6% of ruptured AAA repairs in 2003, with a significant reduction in mortality compared with open repairs for rupture (31.8% vs 50.8%; P < .001). CONCLUSIONS: EVAR is replacing open surgery without an increase in overall case volume. EVAR is responsible for overall decrease in operative mortality even in ruptured aneurysms while decreasing utilization variables. Reimbursement to hospitals is shrinking, however.