Outcomes after Abdominal Aortic Aneurysm Repair in Those ≥80 Years of Age: Recent Veterans Affairs Experience

n = 231) of the patients. A total of 5833 patients underwent repair of nonruptured AAA: mortality was 4.1% (228/5627) in those <80 and 8.25% (17/206) in those ≥80 years old (p < 0.009). Logistic regression analysis indicated age ≥80 was independently associated with higher mortality (odds ratio 1.834:1, 95% bounds 1.117-3.012). Octogenarian status (defined as ≥80 years of age), however, had a less important association with in-hospital death than did surgical complications of the heart or genitourinary tract, postoperative hemorrhage, septicemia, respiratory insufficiency, myocardial infarction (MI), acute renal failure, surgical complications of the central nervous system (CNS), aneurysm rupture, postoperative shock, or disseminated intravascular coagulation (DIC), in ascending order of importance. Only 5.9% (n= 25) of the 427 patients undergoing repair of ruptured AAA were ≥80 years old. In those ≥80 undergoing repair of ruptured aneurysms, mortality was 48% which did not differ from the 45% mortality in those <80 (NS). The likelihood that one would be operated for rupture was statistically greater (1.66:1) for those ≥80 years (p < 0.025). Length of stay (LOS) for those ≥80 undergoing AAA repair was longer being 22.3 ± 14.8 days versus 18.3 ± 13.2 days for younger patients (p < 0.001). Mortality and LOS after AAA repair were statistically greater for those ≥80 years of age. Severity of illness, however, was also greater for octogenarians. Patient Management Category (PMC) software defined illness severity was 4.06 ± 1.22 in octogenarians versus 3.84 ± 1.13 for those younger (p < 0.005). Though age ≥80 was independently associated with increased mortality, selected elderly patients could benefit from AAA repair.     

Risk factors and operative results of patients aged less than 66 years operated on for asymptomatic abdominal aortic aneurysm.

OBJECTIVE: To report risk factors, early operative results and survival after repair of asymptomatic abdominal aortic aneurysm (AAA) in patients aged less than 66 years. DESIGN: a retrospective study based on a prospectively updated database in a University hospital. PATIENTS AND METHODS: Between 1985 and 1999, 118 patients of less than 66 years were operated for AAA. Pre-operative risk factors, early complications, operative mortality (<30 days), and survival are compared with that of 333 older patients operated during the same period. RESULTS: Risk factors were similar to older patients. Serious early (<30 days) complications were recorded in 20% of both groups. The operative mortality was 1.7% for the younger patients and 6% for the older (n.s.). The eight-year survival of the younger patients was 69%, which was significantly below that of a demographically matched population. The older patients had a significantly poorer eight-year survival of 47% (p<0.01), but their relative survival was significantly better (p<0.05). CONCLUSIONS: Younger patients with an AAA were not healthier than older patients. Complications were equally common among both groups. Although the operative mortality was lower, the long-term relative survival was poorer than that of the older patient. Present data do not support a more aggressive surgical attitude towards the younger patients with an asymptomatic abdominal aortic aneurysm, as compared to the older.     

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.     

Aneurysm Diameter and Proximal Aortic Neck Diameter Influence Clinical Outcome of Endovascular Abdominal Aortic Repair: A 4-Year EUROSTAR Experience

Our objective was to evaluate the effect of preoperative aneurysm and aortic neck diameter on clinical outcome after infrarenal abdominal endovascular aneurysm repair (EVAR). Data of patients in the European Collaborators Registry on Stent-Graft Techniques for Abdominal Aortic Aneurysm Repair (EUROSTAR) registry base who underwent EVAR with Talent stent grafts were analyzed. Patient characteristics and clinical outcomes were compared among four groups defined by preoperative abdominal aortic aneurysm (AAA) and proximal aortic neck diameter: A, AAA ≤60 mm and neck ≤26 mm; B, AAA >60 mm and neck ≤26 mm; C, AAA ≤60 mm and neck >26 mm; and D, AAA >60 mm and neck >26 mm. Over a 7-year period, 1,317 patients underwent EVAR. Patients in groups B and D were significantly older and had a higher American Society of Anesthesiologists score compared with groups A and C (p=0.002 and 0.003, respectively). Mortality rate was highest in group D (p=0.002), as were rupture and conversion rates (p=0.015 and 0.037, respectively). This study demonstrates that patients with an AAA >60 mm and a proximal aortic neck >26 mm have worse clinical outcome after EVAR. Presented at the Fifteenth Annual Winter Meeting of the Peripheral Vascular Surgery Society, Steamboat Springs, CO, January 28-30, 2005.     

Aneurysm rupture is independently associated with increased late mortality in those surviving abdominal aortic aneurysm repair

PURPOSE: The aim of this study was to define whether veterans who survived repair of ruptured abdominal aortic aneurysms (AAA) experienced late survival rates similar to those surviving repair of intact AAA. METHODS: All veterans undergoing AAA repair in DRGs 110 and 111 during fiscal years 1991-1995 were identified using the Veterans Affairs (VA) Patient Treatment File (PTF). Late mortality was defined using VA administrative databases including the Beneficiary Identification and Record Locator System and PTF. Illness severity and patient complexity were defined using PTF discharge data that were further analyzed by Patient Management Category software. Veterans were followed up to 6 years after AAA repair. RESULTS: During the study, 5833 veterans underwent repair of intact AAA while 427 had repair of ruptured AAA in all VA medical centers. Operative mortality was defined as that which occurred within 30 days of surgery or during the same hospitalization as aneurysm repair. For those undergoing repair of intact AAA, operative mortality thus defined was 4.5% (265/5833). Operative mortality was 46% (195/427) after repair of ruptured AAA. Overall mortality (including operative mortality) during 2.62+/-1.61 years follow-up was 22% (1282/5833) with intact AAA versus 61% (260/427) for those with ruptured AAA (P<0.001). Further analysis of survival outcomes was performed in patients who survived AAA repair (i.e., those who were discharged alive and lived 30 days or more after surgery). Of those who initially survived repair of ruptured AAA, 28% (65/232) died during follow-up versus 18% (1017/5568) who initially survived repair of intact AAA (odds ratio 1.74; 95% confidence limits 1.30-2.34; P<0.001). In those initially surviving AAA repair, stepwise logistic regression analysis revealed that increasing age, illness severity, patient complexity, as well as AAA rupture and aortic graft complications were increasingly and independently associated with late mortality. Mean survival time was 1681 days for those who survived >30 days and who were discharged alive after repair of ruptured AAA versus 1821 days for those who initially survived repair of intact AAA (P< 0.001). CONCLUSIONS: In addition to higher postoperative mortality rates with ruptured AAA, mortality during follow-up for survivors of AAA repair was also greater for those who survived repair of ruptured AAA. The toll taken by ruptured abdominal aortic aneurysms did not end in the immediate postoperative period.     

The 30-day mortality of ruptured abdominal aortic aneurysms: influence of gender, age, diameter and comorbidities

AIM: The aim of this study was to determine the influence of gender, age, the aneurysm diameter and comorbidity on the 30-day mortality after open repair of ruptured abdominal aortic aneurysms (AAA). METHODS: Between January 1, 1993, and December 31, 2006 all consecutive patients who underwent open repair for a ruptured AAA at the tertiary care of Catharina teaching Hospital were included in this study (N=186). Patients who underwent endovascular repair of their ruptured abdominal aortic aneurysms were excluded from this study. Patient and procedure characteristics were collected and analyzed in relation to 30-day mortality. The association between age, gender, diameter of AAA and comorbidity with 30-day mortality was analyzed with c2 are and logistic regression; a P value <0.05 was considered significant. RESULTS: In this study there were 186 patients with ruptured AAA repair with an 30-day mortality of 36.6% (68/186). Among female patient 30-day mortality was 45.8% (11/24) compared with 35.2% (57/162) among male patients (P=0.31). Patients of 80 years and older had a 61.3% (19/31) 30-day mortality where younger patients had 33% (51/155) 30-day mortality (P=0.02). Thirty-day mortality was 47.2% (17/36) for patients with an AAA less than 65 mm compared with 34% (36/104) for patients with an AAA of 65 mm or larger (P=0.16). Multivariate analysis demonstrated age was a significant predictor of ruptured AAA repair mortality (P=0.017). CONCLUSION: In this study, age was the only significant risk factor of 30-day mortality after open repair in patients with ruptured AAA.     

Ruptured inflammatory abdominal aortic aneurysm: insights in clinical management and outcome

BACKGROUND: Ruptured inflammatory abdominal aortic aneurysm (AAA) is relatively rare, and little has been written on the outcome of operative treatment. METHODS: Patients undergoing attempted repair of ruptured inflammatory AAA between 1995 and 2001 were included in a retrospective case-cohort study. Demographic, clinical, and operative factors were analyzed, together with in-hospital morbidity, in-hospital mortality, and duration of postoperative hospital stay. RESULTS: Of 297 patients who underwent attempted operative repair of ruptured AAA, 24 (8%) had an inflammatory aneurysm. Twenty-two patients were men, and two were women; median age was 69 years (range, 51-85 years). Operative findings revealed a contained hematoma in 16 patients (70%), free rupture in 3 patients (13%), aortocaval fistula in 4 patients (17%), and aortoenteric fistula in 1 patient (4%). Of 273 noninflammatory ruptured AAAs, only 2 AAA (1%) were associated with primary aortic fistula. Ten patients (42%) with inflammatory AAA died in hospital, compared with 117 of 273 patients (43%) without inflammation. Median postoperative stay was 10 days (range, 0-35 days). Of the 14 patients with inflammatory lesions who survived, 11 had postoperative complications; 4 patients had acute renal failure, three of whom required temporary renal replacement therapy. CONCLUSIONS: Ruptured inflammatory AAA is associated with a higher incidence of aortic fistula than is ruptured noninflammatory AAA. Repair of ruptured inflammatory AAA is not associated with increased operative mortality compared with repair of ruptured noninflammatory AAA.     

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.)     

Predictors of Outcome After Abdominal Aortic Aneurysm Rupture: Edinburgh Ruptured Aneurysm Score

Background Many surgeons adopt a selective policy of intervention for a ruptured abdominal aortic aneurysm (AAA). This study aimed to develop an objective method of identifying patients suitable for attempted repair. Methods Consecutive patients selected for attempted repair of ruptured AAA over a 31-month period (January 2000 to July 2002) were entered into an observational study. Altogether, 53 preoperative physiological and biochemical variables were recorded and related to operative outcome. Results A total of 105 patients underwent attempted repair of a ruptured AAA. There were 39 (37%) deaths in hospital or within 30 days of operation. On univariate analysis, hemoglobin <9 g/dl (p = 0.038), blood pressure <90 mmHg (p = 0.036), and Glasgow Coma Scale <15 (p = 0.016) were found to be risk factors that predicted death. Of 70 patients with no or one risk factor, 20 (29%) died. Of 30 patients with two factors, 15 (50%) died, and of the five patients with all three factors, four (80%) died. There was a significant association between mortality and cumulative risk factors (p = 0.003). Conclusion These three risk factors are easily assessed in the emergency setting and might form the basis of a scoring system to inform the outcome of ruptured AAA.     

Payer status is related to differences in access and outcomes of abdominal aortic aneurysm repair in the United States: Boxter LK,Dimick JB,Wainess RM,et al. Surgery 2003;134L:142-5

ConclusionThere were greater operative mortality rates in uninsured patients for both elective and emergent abdominal aortic aneurysm (AAA) repair. Uninsured patients underwent treatment for ruptured AAAs more often than did patients with private insurance.SummaryThe authors studied whether patients with private insurance, compared with patients with Medicaid or no insurance, differ with respect to outcome of AAA repair and timely access to treatment of AAA.The national inpatient procedure diagnostic codes for AAA repair, intact and ruptured, were examined for 5363 patients younger than 65 years, from 1995 to 2000, with risk-adjusted analyses for access to AAA treatment and outcomes of repair. Dependent variables included in-hospital mortality, ruptured AAA, and intact AAA. Independent variables were comorbid disease, gender, age, race, payer status, and median income.Patients with no insurance or Medicaid were more likely to have AAA rupture (P < .001). Patients without insurance were at increased risk for rupture compared with patients with private insurance (odds ratio, 2.3; 95% confidence interval, 1.5-3.5; P < .001). Operative mortality rates appeared greater after elective AAA repair in patients with no insurance or Medicaid compared with patients with private insurance. Operative mortality rates were also higher after ruptured AAA repair in patients without insurance or Medicaid.CommentAdditional analyses are needed to determine whether patients without insurance or with Medicaid tend to avoid health care because of the financial burden or whether delayed access to surgical treatment results from gate-keeping issues or other deterrents to health care among patients with no insurance or Medicaid.     

Young Age Influences Treatment but not Outcome of Colon Cancer

Background Early age at onset is often considered a poor prognostic factor for colon cancer. The aim of this study was to determine the association between age, clinicopathologic features, adjuvant therapy, and outcomes following colon cancer resection. Methods A prospective database of 1327 surgical stage I–III colon cancer patients operated on from 1990–2001 was evaluated, and patients grouped by age. Results Sixty-eight patients (5%) were diagnosed at age ≤40 years (younger) compared with 1259 patients diagnosed at age >40 (older). Younger patients were more likely to have left-sided tumors (66% vs 51%, P = .02), but no more likely to present with symptomatic lesions, more advanced tumors, or have worse pathologic features. Younger patients were noted to have more nodes retrieved in their surgical specimens than older patients (median 18 vs 14, P = .001), although the numbers of total colectomies were similar in both groups. Younger patients were also more likely to receive adjuvant chemotherapy, and this was most pronounced in the stage II cohort: 39% vs 14%, P = .003. With a median follow-up of 55 months, 5-year disease-specific survival (DSS) was similar in both study groups: 86% vs 87%, but 5-year overall survival (OS) was significantly higher in the younger patient cohort (84% vs 73%, P = .001). Conclusion Younger patients undergoing complete resection of stage I–III colon cancer had DSS similar to older patients. However, younger patients had more nodes retrieved from their specimens and were more likely to receive adjuvant therapy, especially for node-negative disease. These factors may have contributed to their overall favorable outcome. Presented as a poster at the Society of Surgical Oncology 2007 60th Annual Cancer Symposium, March 15–18, 2007, Washington, D.C.     

Local Expansion of Donation After Circulatory Death Kidney Transplant Activity Improves Waitlisted Outcomes and Addresses Inequities of Access to Transplantation

In the United Kingdom, donation after circulatory death (DCD) kidney transplant activity has increased rapidly, but marked regional variation persists. We report how increased DCD kidney transplant activity influenced waitlisted outcomes for a single center. Between 2002–2003 and 2011–2012, 430 (54%) DCD and 361 (46%) donation after brain death (DBD) kidney‐only transplants were performed at the Cambridge Transplant Centre, with a higher proportion of DCD donors fulfilling expanded criteria status (41% DCD vs. 32% DBD; p = 0.01). Compared with U.K. outcomes, for which the proportion of DCD:DBD kidney transplants performed is lower (25%; p < 0.0001), listed patients at our center waited less time for transplantation (645 vs. 1045 days; p < 0.0001), and our center had higher transplantation rates and lower numbers of waiting list deaths. This was most apparent for older patients (aged >65 years; waiting time 730 vs. 1357 days nationally; p < 0.001), who received predominantly DCD kidneys from older donors (mean donor age 64 years), whereas younger recipients received equal proportions of living donor, DBD and DCD kidney transplants. Death‐censored kidney graft survival was nevertheless comparable for younger and older recipients, although transplantation conferred a survival benefit from listing for only younger recipients. Local expansion in DCD kidney transplant activity improves survival outcomes for younger patients and addresses inequity of access to transplantation for older recipients.     

Hepatectomy as Treatment of Choice for Hepatocellular Carcinoma in Elderly Cirrhotic Patients

In recent decades liver resection has become a safe procedure; however, the outcome of hepatectomies in aged cirrhotic patients is often uncertain. To elucidate early and long-term outcomes of hepatectomy for HCC in the elderly, we studied 241 cirrhotic patients who underwent liver resection for HCC between 1985 and 2003. According to their age at the time of surgery, patients were divided into two groups: aged > 70 years (64 patients) and aged ≤ 70 years (177 patients). Operative mortality was 3.1% in the elderly and 9.6% in the younger group (p = 0.113). Postoperative morbidity and liver failure rates were higher in the younger group (42.4% versus 23.4%, p = 0.0073; 12.9% versus l.6%, p = 0.0065). Five-year survival rates are 48.6% in the elderly group and 32.3% in the younger group (p = 0.081). Considering only radical resections in Child-Pugh A patients, survival remains similar in the two groups (p = 0.072). Disease-free survival is not different in the two groups. A survival analysis performed according to the tumor diameter shows a better survival for elderly Child-Pugh A patients with HCC larger than 5 cm radically resected (50.8% versus 16.1% 5-year survival, p = 0.034). In univariate analysis, tumor size is not a prognostic factor in the elderly, whereas younger patients with large tumors have a worse outcome. Age by itself is not a contraindication for surgery, and selected cirrhotic patients with HCC who are 70 years of age or older could benefit from resection, even in the presence of large tumors. Long-term results of liver resections for HCC in the elderly may be even better than in younger patients.     

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.)     

Radical Resection of Periampullary Tumors in the Elderly: Evaluation of Long-term Results

Increasingly, patients of advanced age are coming for evaluation of periampullary tumors. Although several studies have demonstrated the safety of resecting periampullary tumors in older patients, few long-term survival data have been reported. Between 1983 and 1992 various periampullary masses were resected in 70 patients over age 65 (range 65–87 years). Total pancreatectomy was performed in 11 patients, and 59 patients underwent pancreaticoduodenectomy. The mean duration of hospitalization was 17 ± 15 days. Major complications occurred in 27 patients (39%), and operative mortality rate was 8.5%. Overall median survival was 24 months; and 5-year survival was 25%. Perioperative outcome was compared in patients aged 65 to 74 years and in patients ≥75 years old. The older age group required longer periods in the surgical intensive care unit postoperatively, but the long-term survival was similar in the two age groups. Radical resection with the intent to cure periampullary tumors is safe in selected patients of advanced age, and long-term survival is in the range of expected survival for younger patients with the same tumors.     

Young Adults and Riding Position: Factors that Affect Mortality Among Inpatient Adult Motorcycle Casualties: A Major Trauma Center Experience

Background  In Singapore, road traffic accidents (RTAs) are the second most common cause of deaths in trauma. Motorcycle casualties account for 54% of all fatalities. Studies have shown that the mean age of motorcycle casualties is significantly younger than that of other RTA victims. Methods  We reviewed the mortality of all motorcycle casualties ≥16 years admitted to an acute hospital as emergencies from January 2004 to December 2006. To determine the impact of age on mortality, we divided our patients into two groups, one ≤21 years (younger group) and another >21 years (older group). A subset analysis based on riding position (driver versus passenger) was performed to determine the inpatient mortality rate in these two groups. Results  There were 96 (14%) patients in the younger group and 586 (86%) patients in the older group. The mortality rate for younger motorcycle casualties was significantly higher (14.6% versus 8%; p = 0.04). Also, there were significantly more passengers in the younger group (25% versus 8.4%; p = 0.0001). The mortality rate among young passengers was significantly higher than that among young drivers (29.2% versus 9.7%; p = 0.019). Likewise, the mortality rate of the young passengers was also significantly higher than that among older passengers (29.2% versus 10.2%; p = 0.04). Conclusions  Young motorcycle casualties have a significantly higher mortality rate than older motorcycle casualties. Young passengers have the highest mortality rate and contribute significantly to the death rate among young motorcycle casualties.     

Predictors of Early Discharge following Open Abdominal Aortic Aneurysm Repair

Patients undergoing endovascular abdominal aortic aneurysm (AAA) repair have lower perioperative morbidity and leave the hospital earlier than patients undergoing open repair. However, potential complications require continuous surveillance of endografts and there are few data regarding their long-term fate. If an open operation were well tolerated, this might be a preferable alternative. The purpose of this study was to identify patients with lower morbidity and shorter hospital stay following open AAA repair and to analyze factors that might point to open repair as the preferred approach. We performed a retrospective review of all patients who underwent AAA repair between 1995 and 2000 at our institution. All patients with ruptured aneurysms and those that required renal, celiac, or superior mesenteric reconstructions during the AAA repair were excluded. Patient demographics, preoperative comorbid conditions, intraoperative data, and postoperative complications were analyzed in detail. A total of 115 patients fulfilled the inclusion criteria. There was only one perioperative death (0.9%). The mean hospital stay was 8.1 days. A history of chronic obstructive pulmonary disease (COPD) and longer operative time were independent factors associated with prolonged hospital stay. Forty-one patients (35.6%) left the hospital in 5 or less days. Compared to the group with hospital stay >5 days, these patients had a lower incidence of COPD (7.3% vs. 25.7%, p < 0.05) and smaller-size AAAs (5.6 vs. 6.4 cm, p < 0.0001), and were more often operated on via a retroperitoneal approach (61% vs. 40.5%, p < 0.05). Their time in the operating room was less (3.5 vs. 4.5 hr, p < 0.0001), and they had less estimated blood loss (750 vs. 1500 cc, p < 0.001) and fewer transfusions (0.95 vs. 2.45 units, p < 0.0001). Patients without COPD and smaller AAAs that can be repaired via a retroperitoneal approach have a lower incidence of perioperative complications and a shorter hospital stay following open AAA repair. Until long-term results for endografts are available, our data suggest that these patients are well served with an open repair.     

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.     

Clinical outcomes of elderly patients undergoing chronic peritoneal dialysis: experiences from one center and a review of the literature

Objectives The purpose of this study was to evaluate the outcome and to identify predictors of mortality in elderly patients on chronic peritoneal dialysis (CPD). Methods We retrospectively reviewed the charts of patients who started on CPD at the Division of Nephrology, University Health Network (UHN), Toronto, from 1 January 1994 to 31 December 2001. Patients were divided into three different age groups (≤64 years, 65–74 years, and ≥75 years). Baseline variables included demographics, information on primary kidney disease, comorbidities when dialysis was first started, and initial biochemical data such as serum albumin, serum calcium (corrected for protein), phosphate, hemoglobin (Hb), total cholesterol, and triglyceride. The effects of these variables on survival were studied using a univariate procedure and then analyzed using multivariate Cox proportional hazards models in order to evaluate their independent relation to mortality. Results This study included 358 patients, among whom 213 (59.5%) were ≤64 years old; 88 (24.6%) were 65–74, and 57 (15.9%) were ≥75 years old. Mean actuarial (death-censored) technique survival for the overall study population was 72.4 months (95% confidence interval [CI]: 66.3–78.5); in the ≤64, 65–74, and ≥75 year-old groups mean survivals were 74.4, 62.0, and 64.5 months, respectively. The death-censored technique survival for the elderly patients was not statistically significantly different from that in young patients (P = 0.778). In the overall study population, the mean patient survival was 70.4 months (95% CI 64.2–76.6), while the mean survivals for the ≤64, 65–74, and ≥75 year-old groups were 82.3, 54.0, and 50.0 months, respectively. The overall survival rates at 12 months were 98%, 84%, and 85% for the ≤64, 65–74, and ≥75 year-old groups, respectively. Not surprisingly, the survival of elderly patients on CPD is shorter than that of younger patients (P = 0.000). There were no significant differences between the two elderly groups (P = 0.439). Mortality was predicted by lower initial serum total cholesterol and albumin as well as higher serum calcium levels. Conclusion Our study shows that elderly patients starting CPD had a death-censored technique survival comparable to that of younger patients. As expected, the survival of elderly patients on CPD was shorter than the survival of younger patients. Lower initial serum total cholesterol and albumin as well as higher initial serum calcium were associated with mortality in the elderly population. Our findings indicate that chronic peritoneal dialysis is a successful dialysis option for elderly patients with end stage renal disease. Measures to improve their nutritional state and achieve normalization of serum calcium might improve their survival.     

Comparable perioperative mortality outcomes in younger patients undergoing elective open and endovascular abdominal aortic aneurysm repair

BackgroundEvidence for benefit of endovascular aneurysm repair (EVAR) over open surgical repair for de novo infrarenal abdominal aortic aneurysms (AAAs) in younger patients remains conflicting because of heterogeneous study populations and small sample sizes. The objective of this study was to compare perioperative and short-term outcomes for EVAR and open surgery in younger patients using a large national disease and procedure-specific data set.MethodsWe identified patients 65 years of age or younger undergoing first-time elective EVAR or open AAA repair from the Vascular Quality Initiative (2003-2014). We excluded patients with pararenal or thoracoabdominal aneurysms, those medically unfit for open repair, and those undergoing EVAR for isolated iliac aneurysms. Clinical and procedural characteristics were balanced using inverse propensity of treatment weighting. A supplemental analysis extended the study to those younger than 70 years.ResultsWe identified 2641 patients, 73% (n = 1928) EVAR and 27% (n = 713) open repair. The median age was 62 years (interquartile range, 59-64 years), and 13% were female. The median follow-up time was 401 days (interquartile range, 357-459 days). Unadjusted perioperative survival was 99.6% overall (open repair, 99.1%; EVAR, 99.8%; P < .001), with 97.4% 1-year survival overall (open repair, 97.3%; EVAR, 97.4%; P = .9). Unadjusted reintervention rates were five (open repair) and seven (EVAR) reinterventions per 100 person-years (P = .8). After propensity weighting, the absolute incidence of perioperative mortality was <1% in both groups (open repair, 0.9%, EVAR, 0.2%; P < .001), and complication rates were low. Propensity-weighted survival (hazard ratio, 0.88; 95% confidence interval, 0.56-1.38; P = .6) and reintervention rates (open repair, 6; EVAR, 8; reinterventions per 100 person-years; P = .8) did not differ between the two interventions. The analysis of those younger than 70 years showed similar results.ConclusionsIn this study of younger patients undergoing repair of infrarenal AAA, 30-day morbidity and mortality for both open surgery and EVAR are low, and the absolute mortality difference is small. The prior published perioperative mortality and 1-year survival benefit of EVAR over open AAA repair is not observed in younger patients. Further studies of long-term durability are needed to guide decision-making for open repair vs EVAR in this population.