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.     

Informed consent for abdominal aortic aneurysm repair: assessing variations in surgeon opinion through a national survey

OBJECTIVE: Informed consent discussions for elective abdominal aortic aneurysm (AAA) repair should reflect appropriate risks of the open or endovascular repair (EVAR), but few guidelines exist describing what surgeons should discuss. This study examines expert opinion regarding what constitutes informed consent. METHODS: Design. We conducted an anonymous, web-based, national survey of vascular surgeons. Associations between surgeon characteristics and opinions regarding informed consent were measured using bivariate statistics; multivariable logistic regression was performed to estimate effects adjusted for covariates. Setting. Academic and private practice surgeons were surveyed. Subjects. United States members of the International Society for Vascular Surgery membership. Main Outcome Measure. Surgeons' self-reported opinions regarding the content of informed consent for AAA repair. RESULTS: A total of 199 surgeons completed the survey (response rate 51%). More than 90% of respondents reported that it was essential to discuss mortality risk for both procedures. However, only 60% and 30% of respondents reported that it was essential to discuss the risk of myocardial infarction and stroke, respectively. Opinions varied by procedure regarding the risks of impotence (32% vs 62%; EVAR vs open repair), reintervention (78% vs 17%), and rupture during long-term follow-up (57% vs 17%). Younger and private practice surgeons were more likely to discuss complications compared with older surgeons and those in academic practice. Surgeons who perform predominantly EVAR were more likely to quote higher mortality rates for open repair (odds ration [OR] = 3.1, 95% confidence interval [CI] = 1.4-6.4) and lower reintervention rates for EVAR (OR = 0.3, 95% CI = 0.1-0.7) compared with other surgeons. CONCLUSIONS: This is the first study of the practice of informed consent for AAA repair. The only risk that the vast majority of surgeons agreed should be included in informed consent for AAA repair was mortality. Significant variation exists regarding whether other complications should be discussed and what complication rates should be quoted. Surgeon characteristics may influence how risks are presented to patients. Further efforts are needed to develop guidelines to ensure consistent communication of appropriate risk during informed consent for AAA repair.     

Optimal timing of abdominal aortic aneurysm repair after coronary artery revascularization.

OBJECTIVE: The authors ascertained the optimal timing of repair of an abdominal aortic aneurysm (AAA) after coronary artery revascularization. SUMMARY BACKGROUND DATA: Cardiac events are the most common cause of death after elective repair of AAA. Preoperative coronary revascularization has significantly reduced postoperative cardiac complications after elective AAA repair. Currently, most patients undergo repair of asymptomatic AAA within 6 months after the coronary revascularization. METHODS: The authors performed a retrospective review of patients who underwent repair or scheduled repair of an asymptomatic AAA within 6 months after coronary artery bypass graft (CABG) between March 1988 and October 1993. RESULTS: There was no mortality in the group of patients (n = 14) who underwent repair of AAA simultaneously or within 14 days of coronary revascularization. In contrast, there was a significantly increased mortality rate of 3 of 9 (33%) in patients scheduled to undergo repair of the AAA more than 2 weeks after coronary revascularization (p < 0.05). All nonsurvivors died between 16 and 29 days after CABG, and died as a result of ruptured AAA. CONCLUSION: Elective AAA repair should be undertaken simultaneously or within 2 weeks of coronary artery revascularization because of an increased risk of postoperative AAA rupture seen after this time period. In addition, simultaneous or early postoperative AAA repair does not increase the overall operative risk.     

The role of coronary artery disease in complications of abdominal aortic aneurysm surgery

Coronary artery disease (CAD) is a major cause of morbidity and mortality after elective surgical repair of abdominal aortic aneurysm (AAA). The aim of this study was to determine the relationship between the extent of CAD observed in coronary angiograms (more than 50% stenosis) and the frequency of postoperative myocardial ischemic complications in a consecutive series of 84 patients who underwent elective AAA repair. Ninety-four percent of the patients with clinical evidence of CAD had significant disease as observed in coronary angiograms and eight patients had left main CAD. Seventy-two patients underwent AAA repair with a mortality rate of 1.4%; five patients had preliminary myocardial revascularization, and AAA surgery was not recommended for four patients because of severe cardiac disease. Postoperative myocardial ischemic complications occurred in 13.4% of the patients who had undergone surgery--almost exclusively in patients with clinical evidence of CAD. Both myocardial ischemia and preoperative intervention were more frequent in patients with double- or triple-vessel disease than in patients with less extensive disease. Patients with symptoms and with double- or triple-vessel CAD have a high risk of developing myocardial ischemia after AAA surgery. Preliminary myocardial revascularization may be beneficial in this group of patients.     

Enoxaparin treatment in high-risk trauma patients limits the utility of surveillance venous duplex scanning

OBJECTIVE: The aim of this study was to determine the independent impact of surgeon speciality training (vascular, cardiac, or general surgery) on the 30-day risk-adjusted mortality rate after elective abdominal aortic aneurysm (AAA) surgery. PATIENTS AND METHODS: All patients undergoing elective AAA surgery in Ontario between April 1, 1992, and March 31, 1996, were included. A retrospective cohort study with linked administrative databases was undertaken. RESULTS: The average 30-day mortality rate was 4.1%. Of the 5878 cases studied, 4415 (75.1%) were performed by 63 vascular surgeons, 1193 (20.3%) by 53 general surgeons, and 270 (4.6%) by 14 cardiac surgeons. After the adjustment for potential confounding factors of annual surgeon AAA volume, type of hospital, and patient age, sex, Charlson comorbidity score, and transfer status, the odds of patients dying were 62% higher when the surgery was performed by a general surgeon than when it was performed by a vascular surgeon. Cardiac surgeons' patient outcomes were similar to those of vascular surgeons. CONCLUSIONS: Patients who undergo elective AAA repair that is performed by vascular or cardiac surgeons have significantly lower mortality rates than patients who have their aneurysms repaired by general surgeons. These results provide evidence that surgical specialty training in vascular procedures leads to better patient outcomes.     

Survival after ruptured abdominal aortic aneurysm: effect of patient, surgeon, and hospital factors

OBJECTIVE: The purpose of this study was to determine the effects of patient, surgeon, and hospital factors on survival after repair of ruptured abdominal aortic aneurysm (AAA) and to compare them with risk factors for survival after elective AAA repair. It was hypothesized that patients operated on by high-volume surgeons with subspecialty training would have better outcomes, which might argue for regionalization of AAA surgery. METHODS: In this population-based retrospective cohort study, surgeon billing and administrative data were used to identify all patients who had undergone AAA repair between April 1, 1992, and March 31, 2001, in Ontario, Canada. Demographic information was collected for each patient, as well as numerous variables related to the surgeons and hospitals. RESULTS: There were 2601 patients with ruptured AAA repair, with an average 30-day mortality rate of 40.8%. Significant independent predictors of lower survival were older age, female gender, lower patient income quintile, performance of surgery at night or on weekends, repair in larger cities, surgeons with lower annual volume of ruptured AAA operations, and surgeons without vascular or cardiothoracic fellowship training. There were 13,701 patients with elective AAA repair, with an average 30-day mortality rate of 4.5%. Significant independent predictors of lower survival were similar, except gender was not significant, but the Charlson Comorbidity Index was. When the hazard ratios associated with predictive factors were compared, surgeon factors appeared to be more important in ruptured AAA repair, and patient factors appeared more important in elective AAA repair. CONCLUSION: For elective AAA repair, and even more so for ruptured AAA repair, high-volume surgeons with subspecialty training conferred a significant survival benefit for patients. Although this would seem to argue in favor of regionalization, decisions should await a more complete understanding of the relationship between transfer time, delay in treatment, and outcome.     

Review of a routine test of cardiac function before aortic aneurysm surgery

The majority of vascular surgeons employ tests of cardiac function prior to embarking on elective abdominal aortic aneurysm (AAA) repair. This study reviewed the value of measuring preoperative ventricular ejection fraction (VEF). The records of the 207 patients considered for elective AAA repair between 1994 and 2000 were reviewed. In patients who underwent surgery, morbidity and mortality data were retrieved from the vascular department database. These outcomes were correlated with the measured VEFs. In patients turned down for surgery, the reasons were determined from patients' notes, and the role that VEF played in the decision was evaluated. Low VEF did not correlate with postoperative cardiac morbidity or mortality. The range of VEF values in patients turned down for surgery was not significantly different from those who underwent AAA repair. VEF was pivotal in the decision not to operate in only one patient over the 6-year interval. This review found no evidence that routine measurement of VEF prior to elective AAA repair was valuable either in making the decision whether to operate or in predicting outcome and complications. Little or no information was added that could not be gained on simple clinical evaluation of cardiac function.     

Conservatism and new technology: the impact on abdominal aortic aneurysm repair

The last decade has represented a time of fundamental change in the treatment of abdominal aortic aneurysms (AAAs). Potentially, vascular surgeons will either acquire catheter-based skills or relinquish the care for many patients with infrarenal AAA. We investigated AAA referral patterns and method of AAA repair after the establishment of an endovascular AAA program at our institution. We conducted a retrospective review of elective AAA repairs after the initiation of an endovascular AAA program in April 1994. Six vascular surgeons performed all procedures with a clear distinction between the surgeons (n=3) who performed traditional AAA repair only and those (n=3) who managed AAAs by means of either endovascular or traditional treatment. From April 1994 through December 2000, 740 elective AAA repairs were performed. During this time the mean number of AAA repairs has been 106/year ranging from 75 to 155/year. More notable however is the steady increase in the percentage of endovascular AAA repairs from 6 per cent of all AAA repairs in 1994 to 61 per cent in 2000. During this time traditional surgeons have experienced a plateau in total AAA repairs performed per year with their number of open repairs decreasing by 36 per cent. At the same time endovascular surgeons have seen a progressive rise in total AAA cases including an increase of 200 per cent in open repairs and of 1367 per cent in endovascular repairs. Our vascular surgeons who repair AAA utilizing both endovascular and open techniques have experienced an increase in aneurysm referrals since the advent of an endovascular AAA program. Those who have not adopted endovascular skills have seen a decline in their aneurysm practice. The larger question about whether or not to embrace new technology before the availability of long-term follow-up remains unanswered.     

Coronary artery disease in patients requiring abdominal aortic aneurysm repair. Selective use of a combined operation.

The chief cause of operative mortality after abdominal aortic aneurysm (AAA) repair is myocardial infarction. For this reason, routine coronary angiography followed by prophylactic coronary artery bypass grafting (CABG) prior to AAA repair has been recommended by some surgeons. We report here the results of the selective use of a combined operation. Two hundred twenty-seven patients had elective or emergency repair of nonruptured AAA on our service from 1972 to 1983. Prior to surgery, all patients underwent careful clinical evaluation for the presence of coronary artery disease (CAD) and were classified into the following: group I (n = 121), no clinical evidence of CAD, 53%; group II (n = 96), clinical evidence of stable CAD, symptomatic or asymptomatic, 42%; group III (n = 10), unstable CAD, five per cent; Group IIIa (n = 4), asymptomatic AAA; and group IIIb (n = 6), symptomatic AAA. Seven patients ultimately assigned to group II underwent stress electrocardiogram (ECG) and eight group II patients had coronary angiography before surgery. All patients in groups I and II underwent elective or urgent repair of their AAA without CABG. Prior to surgery, these patients were managed with placement of a pulmonary artery catheter and incremental volume loading to construct a left ventricular performance curve as a guide to surgical fluid replacement. All were carefully monitored for at least 48 hours after surgery in an intensive care unit. Four patients (group IIIa) with unstable CAD and asymptomatic AAA underwent CABG followed by elective AAA repair within six months. Six patients (group IIIb) with unstable CAD and symptomatic AAA underwent combined open heart surgery (CABG and, in one patient, valve replacement) and AAA repair as a single operation. There was no operative mortality in group III patients. Thirty-day operative mortality for the entire group of 227 patients was 1.3% (three deaths), with only one death from a myocardial infarction (0.4%). While there is clearly a high incidence of CAD in patients with AAA, the present results indicate that these individuals can be managed with low risk by a selective approach based upon clinical assessment of their CAD. Our experience further demonstrates that patients with unstable CAD and symptomatic AAA may have both lesions safely repaired as a single operative procedure.     

Perioperative Cardiac Risk Stratification and Modification in Abdominal Aortic Aneurysm Repair

Cardiovascular complications are important causes of morbidity and mortality following vascular surgery. Adequate preoperative risk assessment and perioperative management may modify postoperative mortality and morbidity and improve long-term prognosis. The objective of this review is to examine the present day knowledge regarding the preoperative evaluation and perioperative management of patients undergoing noncardiac surgery, focusing specifically on abdominal aortic aneurysm (AAA) repair.

Clinical markers combined with ECG and surgical risk assessment can effectively divide patients in a truly low-risk, intermediate and high-risk population. Low-risk patients can probably be operated on without additional cardiac testing. Notably, due to the surgical risk, AAA patients are never low-risk patients. Intermediate-risk and high-risk patients are referred for cardiac testing to exclude extensive stress induced myocardial ischemia, as beta-blockers provide insufficient myocardial protection in this case and preoperative coronary revascularization might be considered. Whether patients at intermediate risk without ischemic heart disease should be treated with statins and/or beta-blockers is still controversial. In high-risk patients, it is strongly advised to administer beta-blockers with heart rate determined dose adjustment, while the effects of preoperative revascularization remain subject to debate.     

The incidence of hypomagnesaemia following abdominal aortic aneurysm surgery

IntroductionMagnesium is important for cardiac function. Hypomagnesaemia is associated with a higher incidence of arrhythmias and poorer outcomes in cardiac surgery. No studies have investigated the incidence or impact of postoperative hypomagnesaemia after abdominal aortic aneurysm (AAA) surgery. We aim to assess the incidence of hypomagnesaemia after AAA repair in our population.MethodsRetrospective analysis was performed of patients who underwent elective AAA surgery at a single vascular centre. The last 110 patients undergoing open or endovascular AAA repair were identified. The hospital pathology system was used to identify the immediate postoperative serum magnesium levels as well as patient demographics and admission details. Hypomagnesaemia was defined as serum magnesium of <0.7mmol/l.ResultsA total of 211 patients were studied and there were 3 deaths. Of the patients included, 101 underwent open elective AAA repair and 110 underwent endovascular repair. In the elective open repair group, 73 patients (73%) were hypomagnesaemic. In the endovascular repair group, 35 (32%) had hypomagnesaemia. A t-test showed a statistically significant difference in hypomagnesaemia between the open and endovascular groups (p<0.001).ConclusionsAAA surgery is associated with a high incidence of postoperative hypomagnesaemia, which is significantly greater among open repair patients. This is likely to have an effect on cardiac activity and lead to cardiac complications such as arrhythmias and poorer postoperative outcomes, especially in the open AAA repair subgroup. This stresses the importance of serum magnesium and cardiac monitoring in the postoperative phase. A prospective study is proposed to further investigate these findings, and their potential implications on perioperative morbidity and mortality.     

Outcome after Simultaneous Abdominal Aortic Aneurysm Repair and Aortocoronary Bypass

Myocardial infarction remains the leading cause of early and late death after abdominal aortic aneurysm (AAA) repair. Myocardial revascularization is staged either before or concomitant with AAA resection, but results are far from uniform. We retrospectively analyzed our experience with patients who underwent concomitant AAA resection and aortocoronary bypass (ACB) to examine the factors affecting early morbidity/mortality and early results. Forty-two patients (all men; mean age, 67.2 years) underwent simultaneous ACB grafting and AAA repair between 1975 and 1998. All were managed postoperatively in the cardiothoracic intensive care unit (mean stay, 6.1 days). The mean total hospital stay was 17.2 days. Two died in the early postoperative period (4.8%): 1 of sustained myocardial failure following a third ACB, and 1 of coagulopathy after concomitant ACB, aortic valve replacement, and AAA. One patient developed a nonfatal MI on postoperative day 3. The incidence of wound and bleeding complications was higher for patients undergoing both ACB and AAA repair than for patients undergoing AAA resection alone. On follow-up (mean, 10 years; range, 7 months to 15 years), only 2 of 10 late deaths were due to cardiovascular causes. We believe that concomitant myocardial revascularization is warranted in select patients requiring elective or urgent AAA resection in order to decrease perioperative risk and improve late survival. Cardiac failure or ischemia during aortic surgery can be prevented by proper perfusion with or without cardiopulmonary bypass. In patients undergoing simultaneous procedures, the increased risk is related to the severity of the vascular and coronary artery disease and not to the combined operations.     

Perioperative cardiac risk stratification and modification in abdominal aortic aneurysm repair

Cardiovascular complications are important causes of morbidity and mortality following vascular surgery. Adequate preoperative risk assessment and perioperative management may modify postoperative mortality and morbidity and improve long-term prognosis. The objective of this review is to examine the present day knowledge regarding the preoperative evaluation and perioperative management of patients undergoing noncardiac surgery, focusing specifically on abdominal aortic aneurysm (AAA) repair. Clinical markers combined with ECG and surgical risk assessment can effectively divide patients in a truly low-risk, intermediate and high-risk population. Low-risk patients can probably be operated on without additional cardiac testing. Notably, due to the surgical risk, AAA patients are never low-risk patients. Intermediate-risk and high-risk patients are referred for cardiac testing to exclude extensive stress induced myocardial ischemia, as beta-blockers provide insufficient myocardial protection in this case and preoperative coronary revascularization might be considered. Whether patients at intermediate risk without ischemic heart disease should be treated with statins and/or beta-blockers is still controversial. In high-risk patients, it is strongly advised to administer beta-blockers with heart rate determined dose adjustment, while the effects of preoperative revascularization remain subject to debate.     

Initial experience of abdominal aortic aneurysm repairs in Borneo

Background: Abdominal aortic aneurysms (AAA) repairs are routineoperations with low mortality in the developed world. There arefew studies on the operative management of AAA in the Asian population.This study reports the initial results from a unit with no previousexperience in this surgery by a single surgeon on completion oftraining. Methods: All patients with AAA repair from a prospective databasebetween 1996 and 1999 in the south‐east Asian state of Sarawak inBorneo Island were analyzed. Three groups were identified on presentationaccording to clinical urgency of surgery. Elective surgery was offeredto all good risk patients with AAA of ≥ 5 cm.All symptomatic patients were offered surgery unless contraindicatedmedically. Results: AAA repairs were performed in 69 patients: 32 (46%)had elective repairs of asymptomatic AAA; 20 (29%) hadurgent surgery for symptomatic non‐ruptured AAA; and 17 (25%)had surgery for ruptured AAA. The mortality rate for elective surgery was6%; the two deaths occurred early in the series with thesubsequent 25 repairs recorded no further mortality. The mortalityrates for the urgent, symptomatic non‐ruptured AAA repair and rupturedAAA repair were 20% and 35%, respectively. Cardiacand res­piratory complications were the main morbidities.Sixty‐three patients seen during this period had no surgery; threepresented and died of ruptured AAA, 34 had AAA of ≤ 5 cmin diameter, and 26 with AAA of ≥ 5 cmdiameter had either no consent for surgery or serious medical contraindications. Conclusion: This study showed that AAA can be repaired safely byhighly motivated and adequately trained surgeons in a hospital withlittle previous experience.     

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.     

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.     

Elective Versus Ruptured Abdominal Aortic Aneurysm Repair: A 1-Year Cost-Effectiveness Analysis

Abdominal aortic aneurysm (AAA) is a life-threatening condition with an overall mortality of 80%. It predominantly affects men 65-74 years of age and is caused by focal distension of the main blood vessel in the abdomen. Most patients go undetected until their aneurysm ruptures. Controversy surrounds the most appropriate form of screening for AAA. Currently, screening is only carried out selectively in patients with peripheral vascular disease. Some patients have their AAA detected incidentally, whilst ultrasound examination of the abdomen is carried out for other indications. These patients have the opportunity to undergo surveillance or elective surgery. The mortality rate of emergency surgical intervention following rupture (50%) is far worse in comparison to that of patients undergoing planned intervention under specialist vascular surgeons (5%). Despite improvements in outcomes from elective intervention for AAA as a result of specialisation, the overall mortality from this condition remains very high (80%) as the commonest presentation of an AAA is rupture. Screening all men aged 65-74 years is considered too costly in the current economic climate. However the cost difference between elective repair and emergency repair of AAA must be considered given that the outcome from elective AAA repair is far superior to that following ruptured AAA repair. Our objective was to retrospectively collect costs and outcomes of elective and emergency AAA repair in order to carry out a cost-effectiveness analysis. Four multiprofessional teams in accident and emergency, operation theatres, intensive care, and surgical wards at the Kent and Canterbury Hospital were selected from health-care professionals including doctors, managers, nurses, and clerical staff with the purpose of obtaining costs. Detailed cost data collection sheets were prepared to calculate costs, which included staff costs, consumables including drugs, intravenous fluids, equipment, investigations, laundry, catering, and stationery. An inventory of costs per item was obtained, and the total cost was calculated from the number of items used. Outcomes were measured in terms of survival. The total costs of emergency AAA repair were ￡96,700.69, with a cost per life saved of ￡24,175.17. The total cost of elective AAA repair was ￡76,583.22, with a cost per life saved of ￡5,470.23. Emergency intervention for AAA was found to cost five times more than a planned intervention per life saved per year.     

Comparison of risk-scoring methods in predicting the immediate outcome after elective open abdominal aortic aneurysm surgery.

BACKGROUND & OBJECTIVES: The aim of this study was to apply three simple risk - scoring systems to prospectively collected data on all elective open Abdominal Aortic Aneurysm (AAA) operations in the Cambridge Academic Vascular Unit over a 6 - year period (January 1998 to January 2004), to compare their predictive values and to evaluate their validity with respect to prediction of mortality and post-operative complications. METHODS: 204 patients underwent elective open infra-renal AAA repair. Data were prospectively collected and risk assessment scores were calculated for mortality and morbidity according to the Glasgow Aneurysm Score (GAS), VBHOM (Vascular Biochemistry and Haematology Outcome Models) and Estimation of Physiologic Ability and Surgical Stress (E-PASS). RESULTS: The mortality rate was 6.3% (13/204) and 59% (121/204) experienced a post-operative complication (30-day outcome). For GAS, VBHOM and E-PASS the receiver operating characteristics (ROC) curve analysis for prediction of in-hospital mortality showed area under the curve (AUC) of 0.84 (95% confidence interval [CI], 0.76 to 0.92; p<0.0001), 0.82 (95% CI, 0.68 to 0.95; p=0.0001) and 0.92 (95% CI, 0.87 to 0.97; p<0.0001) respectively. There were also significant correlations between post-operative complications and length of hospital stay and each of the three scores, but the correlation was substantially higher in the case of E-PASS. CONCLUSIONS: All three scoring systems accurately predicted the risk of mortality and morbidity in patients undergoing elective open AAA repair. Among these, E-PASS seemed to be the most accurate predictor in this patient population.     

Factors affecting late survival after elective abdominal aortic aneurysm repair.

BACKGROUND: The late prognosis after repair of an abdominal aortic aneurysm (AAA) may be affected by atherosclerosis, which involves various organs including the aorta. METHODS: The influence of organ dysfunction and atherosclerosis on the long-term survival of 338 consecutive patients undergoing successful elective AAA repair between 1980 and 1997 was analysed using Cox hazards model. Survival rate was compared with that of 349 patients undergoing successful revascularization for aortoiliac occlusive disease (AIOD) during the same interval. RESULTS: Renal dysfunction and a previous history of cerebrovascular events were important variables predicting late death (risk ratio 1.980 and 1.903 respectively), while a history of cardiac disease predicted only cardiac-related death. The survival rate in patients with normal renal function was significantly better than that in those with renal dysfunction (P = 0.0371). Similarly, the survival rate was significantly better in patients without a history of previous cerebrovascular events (P = 0.0414). The survival rate after AAA repair was nearly identical to that of age- and sex-matched patients with grade II or III symptoms who had surgery for AIOD. CONCLUSION: Advanced atherosclerosis with underlying organ dysfunction is a true determinant of long-term survival following elective repair of AAA.     

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.