Surgical repair of ruptured abdominal aortic aneurysms in the state of Maryland: Factors influencing outcome among 527 recent cases

Purpose: Abdominal aortic aneurysm (AAA) rupture has been historically associated with high operative mortality rates. In this community-based, cross-sectional study, we examined factors influencing outcome after operations performed for ruptured AAA (rAAA). Methods: An analysis of a state database identified 3820 patients who underwent AAA repair between 1990 and 1995, including 527 (13.8%) who had an operation for an rAAA. Demographic variables examined included patient age, gender, race, associated comorbidity rates, operative surgeon experience with rAAA, and annual hospital rAAA and total AAA operative volumes. Outcomes measured included operative mortality rates, hospital length of stay, and charges. Results: Operative mortality rates increased significantly with advancing age (P < 0.0001) but were not related to gender (P = 0.474) or race (p = 0.598) and were significantly lower among patients with hypertension (P = 0.006) or pulmonary disease (P = 0.045). There was no relationship between hospital rAAA or total AAA volume and rAAA repair mortality rate, although high-volume surgeons (i.e., performing more than 10 rAAA repairs) had decreased mortality rates and hospital charges compared with other surgeons. Hospital lengths of stay and charges increased with age among survivors, but not nonsurvivors, of rAAA repair. Despite a stable incidence of rAAA repairs during the study interval and no significant change in the mean age of patients undergoing operation or the percentage of operations performed by high-volume surgeons, the statewide mortality rate declined from 59.3% to 43.2% (P = 0.039). Conclusion: The incidence of rAAA does not appear to be declining. Although operative rAAA repair continues to be associated with substantial risk and remains an especially lethal condition among the elderly, the operative mortality rate has declined in recent years in Maryland. Lower operative mortality rates and hospital charges are associated with operations performed by high-volume surgeons. (J Vasc Surg 1998;28:413-21.)     

Abdominal aortic aneurysm repair in Veterans Affairs medical centers

Purpose: This study was performed to define outcomes after abdominal ortic aneurysm (AAA) repair in Veterans Affairs (VA) medical centers during fiscal years 1991 through 1993.Methods: With VA patient treatment file data, patients were selected from diagnosis-related groups 110 and 111 and were then classified in a patient management category. In the categories of repair of nonruptured and ruptured AAA, mortality and postoperative complication rates were defined for patients who underwent AAA repair in VA medical centers during the 3-year study period.Results: Hospital mortality rates were 4.86% (166 of 3419) after repair of nonruptured AAA and 47.0% (126 of 268) after repair of ruptured AAA ( p < 0.001). Of 292 deaths after AAA repair, 126 (43.2%) followed repair of ruptured AAA, even though ruptured AAA comprised only 7.3% of total AAA surgical volume. AAA repairs were performed at 116 VA medical centers, with 31.8 ± 23.1 (range, 1 to 140) procedures performed at each center. Although many lower-volume centers had excellent results, centers that performed ≥32 AAA repairs tended to have lower in-hospital mortality rates after repair of nonruptured AAA than those that performed ≤31 procedures (4.2% ± 3.5% compared with 6.7% ± 7.8%; p < 0.05). Poisson regression analysis revealed an inverse relationship between the volume of AAA repairs and individual hospital mortality ( p = 0.001) and a direct relationship between illness severity and hospital mortality ( p = 0.008). The proportion of ruptured AAAs treated in a hospital was also directly related to individual hospital mortality rates ( p < 0.005). Postoperative complications were associated with an increased hospital mortality rate (11.7% with complication compared with 6.5% without; p < 0.001) and length of stay (23.6 ± 17.1 days compared with 18.0 ± 12.4 days; p < 0.0001). In a logistic regression model, increased mortality rates after AAA repair were associated with hospital type (adjusted odds ratio [OR] = 0.6), increasing age (OR = 1.1), patient management category severity score (OR = 2.2), hemorrhage (OR = 2.3), myocardial infarction (OR = 2.6), disseminated intravascular coagulation (OR = 4.7), AAA rupture (OR = 6.0), postoperative shock (OR = 10.7), cardiopulmonary arrest (OR = 15.4), central nervous system complications (OR = 16.0) and urologic complications (OR = 2.4).Conclusions: Mortality rates after AAA repair in VA hospitals were comparable with those previously reported in other large series. Outcomes for veterans with AAA may improve by referring patients eligible for elective repair to VA medical centers with a greater operative volume or to lower-volume centers that have had excellent results. (J VASC SURG 1996;23:191-200.)     

A safety,length of stay,and cost analysis of minimally invasive microsurgery for anterior circulation aneurysms

Objectives

The aim of our study was to evaluate minimally invasive techniques for the treatment of anterior circulation aneurysms versus standard surgery, and to calculate the impact of these techniques on health resources, length of stay, and treatment costs.

Methods

A consecutive series of 24 patients with ruptured and 30 with unruptured anterior circulation aneurysms treated with minimally invasive microsurgery (MIM) by the same surgeon was compared with a matched series of standard microsurgeries (SM) conducted for 23 ruptured and 22 unruptured aneurysms. Complication rates, aneurysm obliteration, modified Rankin Scale (mRS) outcomes, length of stay, and treatment costs were assessed.

Results

Surgical complications, aneurysm obliteration rates and mRS outcomes were comparable between MIM and SM groups in ruptured and unruptured aneurysm cohorts. MIM resulted in shorter operative times both in unruptured (102.7?±?4.35 vs 194.7?±?10.26 min, p?<?0.0001) and ruptured aneurysms (124.3?±?827 vs 209?±?13.84 min, p?<?0.0001). Length of stay was reduced in patients with MIM for unruptured aneurysms (1.55?±?24 vs 4.28?±?0.71 days, p?<?0.000,1) but not in those with ruptured aneurysms. MIM reduced treatment costs of unruptured aneurysm patients, mainly through reduced utilization of inpatient resources (non-acute bed costs in CAD: 371.2?±?80.99 vs 1440?±?224.1, p?<?0.0001), whereas costs were comparable in patients with ruptured aneurysms.

Conclusion

Minimally invasive surgery is a safe and effective approach for the treatment of ruptured and unruptured aneurysms of the anterior circulation. In patients with unruptured aneurysms, reduced invasiveness and shorter operative times decreased length of stay, which reflects improved patient postoperative recovery. Overall, this translated into bed resource economy and cost reduction.     

Influence of age and hospital volume on the results of carotid endarterectomy: A statewide analysis of 9918 cases

Purpose: This study evaluated the impact of patient age and hospital volume on the results of carotid endarterectomy (CEA) in contemporary practice. Methods: The Maryland Health Services Cost Review Commission (MHSCRC) database was reviewed to identify all patients who underwent elective CEA as the primary procedure in all acute care hospitals in the state over the past 6 years. Results: From January 1990 through December 1995, 9918 elective CEAs were performed in 48 hospitals at a total charge of $68.9 million. Postoperative death and neurologic complications occurred in 90 (0.9%) and 166 (1.7%) cases, including 0.8% and 1.7%, 0.9% and 1.6%, 0.9% and 1.8%, and 1.4% and 1.3% of patients <65 years, 65 to 69 years, 70 to 79 years, and ≥80 years old, respectively. The mean length of stay and hospital charges increased linearly with increasing age: 4.2 days/$6550, 4.4 days/$6834, 4.8 days/$7059, and 5.6 days (p < 0.0001 vs others)/$7756 (p < 0.005 vs 70 to 79 years and p < 0.0003 vs <70 years old), respectively, for patients <65, 65 to 69, 70 to 79, and ≥80 years old. The mortality rate was 1.9% in low-volume hospitals, 1.1% in moderate-volume hospitals, and 0.8% in high-volume hospitals. The neurologic complication rate was significantly higher (6.1%; p < 0.0001) in low-volume when compared with moderate-volume (1.3%) and high-volume (1.8%) hospitals. Conclusions: CEA is a safe procedure in the majority of hospitals in contemporary practice, even among the very elderly, who may experience a longer length of stay and higher charges correlating with their documented greater medical complexity. (J Vasc Surg 1998;27:25-33.)     

Gender differences in abdominal aortic aneurysm prevalence,treatment, and outcome

Purpose: The purpose of this study was to investigate gender differences in the management of and outcome of surgery for abdominal aortic aneurysms (AAA).Methods: Hospital discharge data from all acute care hospitals in Michigan, as compiled in the Michigan Inpatient Data Base, were retrospectively analyzed to assess sex differences in regard to AAA prevalence, treatment, and surgical outcome from 1980 to 1990. This population database included 11,512 women and 29,846 men 50 years of age and older with diagnoses of intact or ruptured AAA.Results: Hospitalizations for intact or ruptured AAA were approximately five times more common among men compared with women. After controlling for age and year of surgery, men were 1.8 times as likely as women to have an intact AAA treated surgically and 1.4 times as likely to have a ruptured AAA treated surgically (95% confidence intervals, 1.7 to 1.9 and 1.2 to 1.7, respectively). Women who had operations for intact AAA had a 1.4 times greater risk of dying compared with men, and women who had operations for ruptured AAA had a 1.45 times greater risk of dying, after controlling for other predictors of death (95% confidence intervals, 1.14 to 1.73 and 1.10 to 1.90, respectively).Conclusions: In a population-based statewide experience, women who had intact or ruptured AAA were less likely than men to undergo aortic reconstruction and, when they did, were less likely than men to survive to discharge. (J Vasc Surg 1997;25:561-8.)     

Operative mortality rates for intact and ruptured abdominal aortic aneurysms in Michigan: An eleven-year statewide experience

Purpose: The purposes of this study were (1) to determine the current population-based mortality rate for the surgical treatment of abdominal aortic aneurysms (AAA) in Michigan, (2) to document changes in mortality rates over 11 years, and (3) to identify risk factors for operative mortality.Methods: A statewide database provided clinical information on all Michigan hospital admissions with a diagnosis of AAA from 1980 to 1990. The mortality rate analysis included all admissions with a primary diagnosis of AAA that underwent repair. Determination of diagnoses and comorbidities were based on International Classification of Diseases-ninth revision-Clinical Modification codes.Results: Conventional surgical repairs were performed on 8185 intact and 1829 ruptured AAA. Hospital mortality rates accompanying operation for intact AAA decreased from 13.6% in 1980 to 5.6% in 1990 (p < 0.001). Mortality rates over the 11 years averaged 10.7% in women and 6.8% in men (p < 0.001). Mortality rates averaged 10.7% in 4170 admissions of patients 70 years old or older and 4.2% in 4015 admissions of patients 69 years old or younger. Preexistent kidney failure was associated with an average mortality rate of 41.2% compared with 6.2% without this comorbidity. Preexistent dysrhythmia increased mortality rates from 6.6% to 13.6%. Uncomplicated hypertension, cerebrovascular disease, chronic obstructive pulmonary disease, diabetes, arterial occlusive disease, and ischemic heart disease in recent years were not associated with increased mortality rates. Hospitals with an annual volume of 21 or more intact AAA repairs had a surgical mortality rate of 6.2%, compared with 8.9% in hospitals with lower surgical volume (p < 0.001). Mortality rates for surgical repair of ruptured AAA averaged 49.8% and did not improve significantly over the 11 years studied.Conclusion: Despite a dramatic drop in surgical mortality rates, repair of intact AAA remains a formidable undertaking. This population-based series documents a substantially higher mortality rate than most selected series. The unchanged mortality rate for ruptured AAA suggests that development of better algorithms to identify those AAA most apt to rupture and earlier intervention in those instances is likely to improve patient survival rates. (J VASC SURG 1994;19:804-17.)     

Surgeon specialty and provider volumes are related to outcome of intact abdominal aortic aneurysm repair in the United States

OBJECTIVE: This study was undertaken to determine the relative importance of surgeon specialty, hospital volume, and surgeon volume on outcome after abdominal aortic aneurysm (AAA) repair. METHODS: Data were reviewed for 3912 patients undergoing AAA repair in the Nationwide Inpatient Sample during 1997. In-hospital mortality was compared between high-volume hospitals and low-volume hospitals and between high-volume surgeons and low-volume surgeons. High-volume hospitals performed more than 35 AAA repairs per year, and high-volume surgeons performed more than 10 AAA repairs per year. Vascular, cardiac, and general surgery specialization was identified by analysis of other procedures performed by each surgeon. RESULTS: Overall, AAA repair mortality was 4.2%, and was lower at high-volume hospitals (3.0%) than at low-volume hospitals (5.5%) (P <.001). Lowest mortality was associated with operations performed by vascular surgeons (2.2%) compared with cardiac surgeons (4.0%) and general surgeons (5.5%) (P <.001). Mortality rates were also lower for high-volume hospitals (2.5%) compared with low-volume hospitals (5.6%) (P <.001). In a risk-adjusted analysis, high-volume hospital, vascular surgery specialty, and high-volume surgeon were all independently associated with lower risk of in-hospital mortality. In this analysis, risk reduction was 30% for high-volume hospitals (95% confidence interval [CI], 2%-51%; P <.05) and 40% for surgery by a high-volume surgeon (95% CI, 12%-60%; P =.01). AAA repair by general surgeons compared with vascular surgeons was associated with 76% greater risk for death (95% CI, 10%-190%; P =.02). No significant difference in mortality was found between cardiac and vascular surgeons. CONCLUSIONS: High surgeon volume and hospital volume of AAA repair were both associated with lower mortality compared with low-volume providers. Increased specialization in vascular surgery was associated with markedly decreased mortality independent of AAA repair volume. Health policy in support of selective referral for AAA repair should consider surgical specialization in addition to provider volume thresholds.     

Long-term survival and late complications after repair of ruptured abdominal aortic aneurysms

Purpose:Long-term survival and late vascular complications in patients who survived repair of ruptured abdominal aortic aneurysms (RAAA) is not well known. The current study compared late outcome after repair of RAAA with those observed in patients who survived elective repair of abdominal aortic aneurysms (AAA). Methods:The records of 116 patients, 102 men and 14 women (mean age: 72.5 (8.3 years), who survived repair of RAAA (group I) between 1980 to 1989 were reviewed. Late vascular complications and survival were compared with an equal number of survivors of elective AAA repair matched for sex, age, surgeon, and date of operation (group II). Survival was also compared with the age and sex-matched white population of west-north central United States. Results:Late vascular complications occurred in 17% (20/116) of patients in group I and in 8% (9/116) in group II. Paraanastomotic aneurysms occurred more frequently in group I than in group II (17 vs. 8,p = 0.004). At follow-up, 32 patients (28%) were alive in group I (median survival: 9.4 years) and 53 patients (46%) were alive in group II (median survival: 8.7 years). Cumulative survival rates after successful RAAA repair at 1, 5, and 10 years were 86%, 64%, and 33%, respectively. These were significantly lower than survival rates at the same intervals after elective repair (97%, 74%, and 43%, respectively, p = 0.02) or survival of the general population (95%, 75%, and 52%, respectively,p < 0.001). Coronary artery disease was the most frequent cause of late death in both groups. Vascular and graft-related complications caused death in 3% (3/116) in group I and 1% (1/116) in group II. Cox proportional hazards modeling identified age p = 0.0001), cerebrovascular disease p = 0.009), and number of days on mechanical ventilation p = 0.01) to be independent prognostic determinants of late survival in group I. Conclusions:Late vascular complications after repair of RAAA were higher and late survival rates lower than after elective repair. These data support elective repair of AAA. As two-thirds of the patients discharged after repair of RAAA are alive at 5 years, aggressive management of RAAA remains justified. (J Vasc Surg 1998;27:813-20.)     

Patient selection and perioperative outcomes are similar between targeted and nontargeted hospitals (in the National Surgical Quality Improvement Program) for abdominal aortic aneurysm repair

Objective

The targeted vascular module in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) consists of self-selected hospitals that choose to collect extra clinical details for better risk adjustment and improved procedure-specific outcomes. The purpose of this study was to compare patient selection and outcomes between targeted and nontargeted hospitals in the NSQIP regarding the operative management of abdominal aortic aneurysm (AAA).

Angiographic characteristics of ruptured paraclinoid aneurysms: risk factors for rupture

Background

The diagnosis and treatment of unruptured paraclinoid aneurysms has been increasing with the recent advent of diagnostic tools and less invasive endovascular therapeutic options. Considering the low incidence of rupture, investigation of the characteristics of ruptured paraclinoid aneurysm is important to predict rupture risk of the paraclinoid aneurysms. The objective of this study is to evaluate probable factors for rupture by analyzing the characteristics of ruptured paraclinoid aneurysms.

Methods

A total of 2,276 aneurysms (1,419 ruptured and 857 unruptured) were diagnosed and treated endovascularly or microsurgically between 2001 and 2011. Among them, 265 were paraclinoid aneurysms, of which 37 were ruptured. Removing 12 blister-like aneurysms, 25 ruptured and 228 unruptured saccular aneurysms were included and the medical records and radiological images were retrospectively analyzed.

Results

Of 25 aneurysms, 16 (64.0 %) were located in the superior direction. Five were inferior located lesions (20 %) and four were medially located lesions (16.0 %). Laterally located lesions were not found. The mean size of aneurysms was 9.4?±?5.6 mm. Ten aneurysms (40.0 %) were ≥?10 mm in size. Thirteen aneurysms (52.0 %) were lobulated. The superiorly located aneurysms were larger than the other aneurysms (10.3?±?5.8 mm vs. 7.7?±?4.9 mm) and more frequently lobulated (ten of 16 vs. three of nine). In a comparative analysis, the ruptured aneurysms were located more in the superior direction compared with unruptured aneurysms (64 vs. 23.2 %, p?<?0.0001). Large aneurysms (36.0 vs. 7.9 %, p?<?0.0001), longer fundus diameter (mean 9.4?±?5.6 vs. 4.8?±?3.3 mm, p?=?0.001), dome-to-neck ratio (mean 1.8?±?0.9 vs. 1.2?±?0.5, p?<?0.0001), and lobulated shape aneurysms were more likely to be ruptured aneurysms (13 of 25 ruptured aneurysms, 52.0 %, p?=?0.001).

Conclusions

Rupture risk of the paraclinoid aneurysm is very low. However, superiorly located paraclinoid aneurysms appear more likely to rupture than other locations. Angiographically, more conservative indication for the treatment of paraclinoid aneurysm should be recommended except for superior located lesions.     

The effect of hospital vascular operation capability on outcomes of lower extremity arterial bypass graft procedures

BACKGROUND: The purpose of this study was to determine whether hospitals with a high capability for vascular operations have lower rates of inpatient mortality, major complication, and major amputation with lower extremity arterial bypass (LEAB) procedures than do less well-equipped hospitals after controlling for hospital procedure volume and patient characteristics. METHODS: Admissions of 16,422 northern Illinois residents to Illinois hospitals for aortoiliac (AI) or distal bypass operations during 1993 to 1999 were analyzed. Hospitals were considered to have a high capability for vascular operations if they had cardiac surgical facilities and either an accredited blood flow laboratory, general surgical residency, or fellowship training in vascular surgery. Logistic regression was used to model the effect of hospital capability on mortality after controlling for hospital LEAB procedure volume, operation level, severity of illness, age, sex, and emergent admission. RESULTS: Sixteen of 98 Illinois hospitals with 34.4% of the sample patients, including 8 of 18 hospitals with more than 40 admissions for LEAB procedures annually, were classified as having high surgical capability. Hospitals classified as having high versus low capability had lower mortality (2.8% vs 3.7%; P =.003) and amputation rates (4.6% vs 4.9% [not significant]) but higher major complication rates (9.8% vs 8.5%; P =.006). CONCLUSIONS: Mortality outcomes for LEAB procedures were superior at high capability hospitals, even after controlling for patient characteristics, disease severity, and LEAB volume. Hospital complication rates were not correlated with mortality rates and may not be a meaningful measure of quality of care.     

A randomized study on eversion versus standard carotid endarterectomy: Study design and preliminary results: The Everest Trial

Purpose: The EVEREST Trial was designed to determine whether the surgical technique influences the durability and complications of carotid endarterectomy (CEA). The current report focuses on the study design and preliminary results. Methods: EVEREST is a randomized multicenter trial. A total of 1353 patients with carotid stenosis requiring surgical treatment were randomly assigned to received standard (n = 675) or eversion (n = 678) CEA. Primary end points included carotid occlusion, major stroke, death, and restenosis rate. Results: The rate of perioperative major stroke and death (1.3 for each study group) and the incidence of early carotid occlusion (0.6% for eversion vs 0.4% for standard) were similar. No significant differences were found between eversion and standard CEA with respect to incidence of perioperative transient ischemic accident, minor stroke, cranial nerve injuries, neck hematoma, myocardial infarction, or surgical defects as detected with intraoperative quality controls. Clamping time was significantly shorter for eversion CEA compared with patch standard procedures (31.7 ± 15.9 vs 34.5 ± 14.4 minutes, p = 0.02). A shunt was inserted in 11% of patients undergoing eversion CEAs and in 16% of patients undergoing standard procedures. Overall 30-day events occurred in 13.3% of the eversion group and in 11.4% of the standard group (p = 0.3). At a mean follow-up of 14.9 months (range, 1 to 38 months), 16 (2.4%) restenoses occurred in the eversion group and 28 (4.1%) occurred in the standard group (odds ratio, 0.56; 95% confidence interval, 0.3 to 1.1; p = 0.08). Conclusion: The preliminary results of the EVEREST Trial suggest that eversion CEA is a safe and rapid procedure with low major complication rates. No significant differences in restenosis rates were observed between eversion and standard CEA at the available follow-up. Longer-term results are necessary to assess whether the eversion technique influences the durability of CEA. (J Vasc Surg 1998;27:595-605.)     

Epidemiological study of the relationship between volume and outcome after abdominal aortic aneurysm surgery in the UK from 2000 to 2005

BACKGROUND: The aim was to assess the relationship between hospital volume and outcome after abdominal aortic aneurysm (AAA) surgery in the UK. METHODS: Hospital Episode Statistics (2000-2005) were classified as elective, urgent or ruptured AAA repair. Analysis was by modelling of mortality rate, complication rate and length of hospital stay with regard to the annual operative volume, after risk adjustment. RESULTS: There were 112,545 diagnoses, or repairs, of AAAs, of which 26,822 were infrarenal aneurysms. The mean mortality rate was 7.4, 23.6 and 41.8 per cent for elective, urgent and ruptured AAA repair respectively. Elective AAA repair undertaken at high-volume hospitals showed volume-related improvements in mortality (P < 0.001). Patients were discharged from hospital earlier (P < 0.001). The critical volume threshold was 32 elective AAA repairs per year. For urgent repair, patients at high-volume hospitals had a reduced mortality rate (P = 0.017) with an increased length of stay (P = 0.041). There was no relationship between volume and outcome for ruptured AAA repairs. CONCLUSION: Increased annual volumes were associated with significant reductions in mortality for elective and urgent AAA repair, but not for repair of ruptured AAAs.     

A comparison of carotid angioplasty with stenting versus endarterectomy with regional anesthesia

Introduction: Percutaneous transluminal angioplasty with stenting (PTAS) has been considered a potential alternative to carotid endarterectomy (CEA) for stroke prevention. Interventionalists have suggested that PTAS carries less anesthetic risk than CEA. The treatment of carotid stenosis with local or regional anesthesia (LRA) allows direct intraprocedural neurologic evaluation and avoids the potential risks of general anesthesia. Methods: We retrospectively analyzed the clinical charts of 377 patients who underwent 414 procedures for the elective treatment of carotid stenosis in 433 cerebral hemispheres with LRA between August 1994 and May 1997. Group I (312 hemispheres) underwent PTAS, and group II (121 hemispheres) underwent CEA. Results: The indications for treatment included the following: asymptomatic severe stenosis (n = 272; 62.8%), transient ischemic attack (TIA; n = 100; 23.1%), and prior stroke (n = 61; 14.1%). The early neurologic results for the patients in group I (n = 268) included 11 TIAs (4.1%), 23 strokes (8.6%), and 3 deaths (1.1%). The early neurologic results for the patients in group II (n = 109) included 2 TIAs (1.8%), one stroke (0.9%), and no deaths. The total stroke and death rates were 9.7% for the patients in group I and 0.9% for the patients in group II (P = .0015). The cardiopulmonary events that led to additional monitoring were evident after 96 procedures in group I (32.8%) and 21 procedures in group II (17.4%; P = .002). Conclusion: PTAS carries a higher neurologic risk and requires more monitoring than CEA in the treatment of patients with carotid artery stenosis with LRA. The proposed benefit for the use of PTAS to avoid general anesthesia cannot be justified when compared with CEA performed with LRA. (J Vasc Surg 1998;28:397-403.)     

Using volume criteria: do California hospitals measure up?

BACKGROUND: Many studies have demonstrated a significant relationship between high procedural volume and better outcomes. As the public becomes increasingly aware of this medical literature, consumer groups have collaborated with medical researchers to operationalize this body of evidence. One such organization, the Leapfrog Group, has proposed annual volume criteria for four operations: coronary bypass grafting (CABG), abdominal aortic aneurysm (AAA), carotid endarterectomy (CEA), and esophageal cancer resection (ECR). This study analyzes California hospitals within the context of these volume criteria. MATERIALS AND METHODS: Using the California inpatient database from 2000, we identified all CABG, AAA, CEA, and ECR operations performed at metropolitan hospitals. The volume of each of the four operations was tabulated by hospital and evaluated. Comparisons were made between academic and nonacademic hospitals. RESULTS: Most hospitals in California did not meet Leapfrog's volume criteria. Only 2 hospitals of 287 (0.7%) met the volume criteria for the operations that it performed. Of the 71 (25%) hospitals that performed all four procedures, none met the volume criteria of all four procedures. In fact, only 10% of California hospitals performing these operations were high-volume hospitals based on Leapfrog's volume criteria. When comparing academic to nonacademic hospitals, academic hospitals performed more AAA operations than nonacademic hospitals (36 vs 12, P = 0.02). Although academic hospitals tended to have higher caseloads for CABG, CEA, and ECR, these did not reach statistical significance. Also, academic hospitals were more likely to be high volume for AAA (43.8% vs 7.0%, P < 0.01) and for ECR (23.1% vs 4.0%, P < 0.01). CONCLUSIONS: California's hospital system is far from being regionalized. Although academic hospitals appear better positioned than nonacademic hospitals, the vast majority of all hospitals do not meet Leapfrog's volume criteria. As efforts to use volume as a proxy measure of quality gain momentum, hospitals and physicians will be forced to measure and report quality. As such, surgeons need to decide between accepting volume as an adequate measure of quality and developing other possibly more direct and reliable methods.     

Increased hospital volume is associated with improved outcomes following abdominal-based breast reconstruction

Abstract

Previous studies of outcomes following abdominal-based breast reconstruction largely use data from single-centre/surgeon experience. Such studies are limited in evaluating the effect of operative volume on outcomes. Abdominal-based breast reconstructive procedures were identified in the 2009–2010 HCUP Nationwide Inpatient Sample. Outcomes included in-hospital microvascular complications in free flap cases (requiring exploration/anastomosis revision), procedure-related and total complications in all cases, and length of stay (LOS). High-volume hospitals were defined as 90th percentile of case volume or higher (>30 flaps/year). Univariate and multivariate analyses were performed to identify predictors of outcomes. Of the 4107 patients identified, mean age was 50.7 years; 71% were white, 68% underwent free flap reconstruction, and 25% underwent bilateral reconstruction. The total complication rate was 13.2%, and the microvascular complication rate was 7.0%. Mean LOS was 4.5 days. There were 436 hospitals; 59% of cases were performed at high-volume institutions. Patients at high-volume hospitals more often underwent free flap reconstruction compared to low-volume hospitals (82.4% vs 50.5%, p < 0.001). On unadjusted analysis, microvascular complication rates of 6.4% vs 8.2% were observed for high-volume compared to low-volume hospitals (p = 0.080). After adjusting for case-mix, high-volume hospitals were associated with a decreased likelihood of suffering a microvascular complication (OR = 0.71, p = 0.026), procedure-related complication (OR = 0.79, p = 0.033), or total complication (OR = 0.75, p = 0.004). The majority of cases nationwide are performed at a small number of high-volume hospitals. These hospitals appear to discharge patients earlier and have lower microvascular, procedure-related, and total complication rates when controlling for case-mix.     

Variation in death rate after abdominal aortic aneurysmectomy in the United States: impact of hospital volume, gender, and age

OBJECTIVE: To determine whether high-volume hospitals (HVHs) have lower in-hospital death rates after abdominal aortic aneurysm (AAA) repair compared with low-volume hospitals (LVHs). SUMMARY BACKGROUND DATA: Select statewide studies have shown that HVHs have superior outcomes compared with LVHs for AAA repair, but they may not be representative of the true volume-outcome relationship for the entire United States. METHODS: Patients undergoing repair of intact or ruptured AAAs in the Nationwide Inpatient Sample (NIS) for 1996 and 1997 were included (n = 13,887) for study. The NIS represents a 20% stratified random sample representative of all U.S. hospitals. Unadjusted and case mix-adjusted analyses were performed. RESULTS: The overall death rate was 3.8% for intact AAA repair and 47% for ruptured AAA repair. For repair of intact AAAs, HVHs had a lower death rate than LVHs. The death rate after repair of ruptured AAA was also slightly lower at HVHs. In a multivariate analysis adjusting for case mix, having surgery at an LVH was associated with a 56% increased risk of in-hospital death. Other independent risk factors for in-hospital death included female gender, age older than 65 years, aneurysm rupture, urgent or emergent admission, and comorbid disease. CONCLUSIONS: This study from a representative national database documents that HVHs have a significantly lower death rate than LVHs for repair of both intact and ruptured AAA. These data support the regionalization of patients to HVHs for AAA repair.     

Carotid endarterectomy in octogenarians: Early results and late outcome

Purpose: This study was undertaken to determine the safety and efficacy of carotid endarterectomy (CEA) in the octogenarian population at the Cleveland Clinic. Methods: From 1989 to 1995, 182 CEAs were performed among 167 octogenarians (98 men, 69 women) with a mean age of 83 years (median, 83 years; range, 80 to 93 years). One hundred procedures (55%) were performed for severe asymptomatic stenosis, whereas 48 (26%) were performed for hemispheric transient ischemic attacks (TIAs) or amaurosis fugax, 24 (13%) for prior stroke, and 10 (5%) for vertebrobasilar symptoms. Thirteen CEAs (7%) were combined with myocardial revascularization, and another five (3%) represented carotid reoperations. Nine arteriotomies (5%) were closed primarily, whereas the remaining 173 (95%) were repaired using either vein patch angioplasty (141, 77%) or synthetic patches (32, 18%). Two patients were lost to follow-up, but late information was available for 165 patients (180 operations) at a mean interval of 2.7 years (median, 2.4 years; maximum, 7.4 years). Results: Considering all 182 procedures, there were five early (<30 days) postoperative neurologic events (2.7%), including three strokes (1.6%) and two TIAs (1.1%). An additional 15 neurologic events occurred during the late follow-up period, consisting of 11 strokes (6.1%) and four TIAs (2.2%). The Kaplan-Meier estimated 5-year rate of freedom from stroke was 85% (95% confidence interval [CI], 77% to 93%). There was one early postoperative death (0.6%) of cardiac complications 9 days after CEA. The estimated 5-year survival rate was 45% (95% CI, 33% to 57%), and the 5-year stroke-free survival rate was 42% (95% CI, 30% to 53%). Multivariable analysis yielded age at operation (p = 0.001), abnormal creatinine level (p = 0.025), and chronic obstructive pulmonary disease (p = 0.019) as variables that significantly influenced the survival rate. The presence of chronic obstructive pulmonary disease (p = 0.009) and, surprisingly, a lesser degree of contralateral internal carotid stenosis (p = 0.003) were found to be significantly associated with stroke after CEA. Causes of late death were cardiovascular in 16 patients (30%), unknown in 13 (24%), carcinoma in six (11%), stroke in six (11%), and miscellaneous in 13 (24%). Conclusions: We conclude that CEA may be safely performed in selected octogenarians with carotid stenosis, and that the majority of these patients live the rest of their lives free from stroke. Therefore, age alone should not exclude otherwise-qualified candidates from consideration for CEA. (J Vasc Surg 1998;27:860-71.)     

The impact of hospital grade,hospital-volume,and surgeon-volume on outcomes for adults undergoing appendicectomy

IntroductionAcute Appendicitis and appendicectomy are common surgical emergencies worldwide. However, there is a lack of published data on the impact of hospital grade, surgeon- and hospital-volumes on patient outcomes following appendicectomy.AimTo establish if hospital grade, hospital-volume, or surgeon-volume impacted patient outcomes following appendicectomy.MethodsUsing the National Quality Assurance and Improvement System (NQAIS) data for all appendicectomies performed in Ireland between January 2014 and November 2017 were examined. Data relating to patient demographics, type of surgery (open/laparoscopic/laparoscopic converted to open), length of stay (LOS), mortality, admission to critical care and re-admission rates were collected and analysed.ResultsDuring the study period, 15,896 adult appendicectomies were performed, 14,521 were laparoscopic procedures. Patients treated in district general hospitals (DGHs) had lower LOS (2.96 v 3.37 days, p < 0.0001) than patients treated in tertiary referral hospitals (TRHs), had lower rates of laparoscopic procedures (87.38% v 95.56% p < 0.0001) and higher admission rates to critical care (1.91% v 0.75% p < 0.0001). No significant outcome difference was seen between those treated by high-volume (>62 cases/year) or low volume surgeons (<20 cases/year). Patients treated in high-volume hospitals (>260 cases/year) had higher rates of laparoscopic procedures (94.9% v 83.5%, p < 0.0001), lower rates of admission to critical care (0.85% v 2.25%, p < 0.0001) and lower 7-day re-admission rates (2.54% v 3.55%, p = 0.02) than those operated in low-volume hospitals (<161 cases/year).ConclusionPatients operated on in high-volume hospitals benefit from higher rates of laparoscopic surgery and fewer critical care admissions. No significant difference in outcome was noted in those patients operated upon by high- or low-volume surgeons or based on hospital grade.     

Epidemiology and Outcome of Aortic Aneurysms in Hong Kong

Abstract The objective of this study was to determine epidemiology and mortality statistics for abdominal aortic aneurysms (AAAs) in Hong Kong. Data from three sources were obtained and analyzed: (1) Hong Kong Hospital Authority discharge statistics for 1999 and 2000; (2) a survey on aortic aneurysms in public hospitals conducted by the Working Group of Vascular Surgery; and (3) the Department of Surgery, University of Hong Kong Medical Center aortic aneurysm database. The disease pattern, distribution, and operative mortality were determined. The annual incidence of AAA in Hong Kong is 13.7 per 100,000 population and 105 per 100,000 for those aged 65 and above. About 10% of the AAAs that presented were ruptured. The mean age of the AAA patients was 74 years, with 84% of them over age 65. The operative repair rate for AAAs was low, being only 8% for intact aneurysms and 54% for ruptured ones. Overall, 45% of all aneurysm repairs were performed for a ruptured AAA. There is diverse practice between major vascular centers and smaller regional hospitals. The territory-wide operative mortality rates for intact and ruptured aneurysms were 10% (range 4–24%) and 70% (range 38––100%), respectively. There was no gender bias in the rupture and operative rates. The overall mortality was 17% for intact AAAs and 78% for ruptured AAAs. The average length of hospital stay was 19 days for elective AAA surgery and 13 days for ruptured AAAs. The number of operations in high-volume centers is increasing with a concomitant decrease in operative mortality. There are no definitive data to indicate that the incidence of AAAs is rising, but a trend toward an increasing number of operations in referral centers is noted. The low repair rates for intact AAAs and the high proportion of repairs for ruptured aneurysms suggest that AAAs are undertreated in Hong Kong.