Vascular medicine in the 21st century: Embracing comprehensive vasculature evaluation and multidisciplinary treatment

The field of vascular medicine has undergone a profound transformation in the 21st century, transforming our approach to assessment and treatment. Atherosclerosis, a complex inflammatory disease that affects medium and large arteries, presents a major challenge for researchers and healthcare professionals. This condition, characterized by arterial plaque formation and narrowing, poses substantial challenges to vascular health at individual, national, and global scales. Its repercussions are far-reaching, with clinical outcomes including ischemic heart disease, ischemic stroke, and peripheral arterial disease-conditions with escalating global prevalence. Early detection of vascular changes caused by atherosclerosis is crucial in preventing these conditions, reducing morbidity, and averting mortality. This article underscored the imperative of adopting a holistic approach to grappling with the intricacies, trajectories, and ramifications of atherosclerosis. It stresses the need for a thorough evaluation of the vasculature and the implementation of a multidisciplinary treatment approach. By considering the entire vascular system, healthcare providers can explore avenues for prevention, early detection, and effective management of this condition, ultimately leading to improved patient outcomes. We discussed current practices and proposed new directions made possible by emerging diagnostic modalities and treatment strategies. Additionally, we considered healthcare expenditure, resource allocation, and the transformative potential of new innovative treatments and technologies.

Reporting of health-related quality of life in emergency laparotomy trials: a systematic review and narrative synthesis

PURPOSE

Emergency laparotomy is associated with high morbidity for the surgical patient. Understanding patients' health-related quality of life after their surgery is important to enhance the informed consent process, and to enable the evaluation and improvement of surgical care. This review aims to summarise the use of health-related quality of life tools in clinical trials involving patients undergoing emergency laparotomy.

METHODS

A systematic review was undertaken of the scientific literature published in the MEDLINE® and PubMed databases between January 2011 and July 2021. A narrative synthesis approach was chosen to synthesise the diverse range of studies in a structured manner. All included papers were evaluated using the Cochrane Collaboration's tool for assessing risk of bias.

RESULTS

Eleven studies were selected for inclusion. Most of the studies had a low risk of bias. Two of the studies used health-related quality of life as the primary outcome measure. A variety of health-related quality of life measurement tools were used; the EQ-5D tool was the most popular questionnaire. Protocol adherence was dependent on the length of time which had elapsed after emergency surgery.

CONCLUSION

There are many perceived challenges to collecting health-related quality of life data in the emergency surgery setting. Many of these can be offset with progressive trial designs. There is a need for further research in the systematic development of patient-reported outcomes for use in emergency surgery.

The Management of Ruptured Abdominal Aortic Aneurysms: An Ongoing Challenge

BACKGROUND

despite improvements in the diagnosis and treatment of elective AAAs, ruptured abdominal aortic aneurysms (RAAAs) continue to cause a substantial number of deaths. The choice between an open or endovascular approach remains a challenge, as does postoperative complications in survivors. The aim of this manuscript is to offer an overview of the contemporary management of RAAA patients, with a focus on preoperative and intraoperative factors that could help surgeons provide more appropriate treatment.

METHODS

we performed a search on MEDLINE, Embase, and Scopus from 1 January 1985 to 1 May 2023 and reviewed SVS and ESVS guidelines. A total of 278 articles were screened, but only those with data available on ruptured aneurysms' incidence and prevalence, preoperative scores, and mortality rates after emergency endovascular or open repair for ruptured AAA were included in the narrative synthesis. Articles were not restricted due to the designs of the studies.

RESULTS

the centralization of RAAAs has improved outcomes after both surgical and endovascular repair. Preoperative mortality risk scores and knowledge of intraoperative factors influencing mortality could help surgeons with decision-making, although there is still no consensus about the best treatment. Complications continue to be an issue in patients surviving intervention.

CONCLUSIONS

RAAA still represents a life-threatening condition, with high mortality rates. Effective screening and centralization matched with adequate preoperative risk-benefit assessment may improve outcomes.

The controlling nutritional status score predicts postoperative mortality in patients with ruptured abdominal aortic aneurysm: a retrospective study

Background

Ruptured abdominal aortic aneurysms (rAAAs) are challenging for vascular surgeons because they have a high mortality rate. In many diseases, nutritional status is closely associated with prognosis. The Controlling Nutritional Status (CONUT) screening tool score is a prognostic factor in some malignant and chronic diseases; however, the impact of nutritional status on rAAA has not yet been reported. In this study, we explored the relationship between the CONUT score and the postoperative prognosis of patients with rAAA.

Methods

This was a retrospective review of 39 patients with rAAA who underwent surgical treatment from March 2018 to September 2021 at one center. Patient characteristics, nutritional status (CONUT score), and postoperative status were recorded. The patients were divided into groups A and B based on the CONUT score. The baseline characteristics of the two groups were compared, and Cox proportional hazards and logistic regression analyses were used to determine independent predictors of mid-term mortality and complications, respectively.

Results

The overall mid-term mortality rate was 28.21% (11/39). Compared with group A, group B had higher intraoperative (P = 0.047) and mid-term mortality (P = 0.033) rates. The univariate analysis showed that age [hazard ratio (HR), 1.098; 95% confidence interval (CI), 1.019-1.182; P = 0.014], CONUT score (HR, 1.316; 95% CI, 1.027-1.686; P = 0.03), and surgical procedure (HR, 0.127; 95% CI, 0.016-0.992; P = 0.049) were associated with mid-term mortality, whereas the multivariate analysis showed that the CONUT score (HR, 1.313; 95% CI, 1.009-1.710; P = 0.043) was an independent predictor of mid-term mortality. The multivariate logistic regression analysis did not reveal any associations with complications. The Kaplan-Meier curves showed that group B had a lower mid-term survival rate (log-rank P = 0.024).

Conclusion

Malnutrition is closely associated with the prognosis of patients with rAAA, and the CONUT score can be used to predict mid-term mortality.

A Comparison of Endovascular Aneurysm Repair and Open Repair for Ruptured Aortic Abdominal Aneurysms

Management modalities of ruptured abdominal aortic aneurysm (AAA) include ruptured open aneurysm repair (rOAR) and ruptured endovascular aneurysm repair (rEVAR). In this study, we aim to systematically review all the previously published randomized controlled trials (RCTs) that compared rOAR and rEVAR. A systematic search was performed in the following databases: PubMed, Scopus, Web of Science, Google Scholar, Clinical trials, and others with all the potentially relevant keywords that were adjusted to meet the search strategy for each database to collect all the relevant studies that were published up to January 2021. A total of 11 studies were identified through our comprehensive search. Among these studies, seven represented the IMPROVE trial, two represented the AJAX trial, and two represented the Nottingham and ECAR trials, each, while the remaining four studies were not RCTs; however, these were included in the discussion as they obtained data from the IMPROVE trial. The IMPROVE trials preferred EVAR use due to the potential survival benefit and improved quality of life, although the EVAR and OAR had similar mortality rates. In the AJAX and ECAR, the mortality rates favored EVAR over OAR with no significance while the opposite was noticed in the Nottingham trial with no significance also. Similar rates of re-interventions and complications were also noticed and some studies reported that EVAR is cost-effective. Overall evidence slightly favors EVAR over OAR and further studies are needed.

Identification of Risk Factors and Development of Predictive Risk Score Model for Mortality after Open Ruptured Abdominal Aortic Aneurysm Repair

Background and Objectives: Despite the relatively large number of publications concerning the validation of these models, there is currently no solid evidence that they can be used with absolute precision to predict survival. The goal of this study is to identify preoperative factors that influenced 30-day mortality and to create a predictive model after open ruptured abdominal aortic aneurysm (RAAA) repair. Materials and Methods: This was a retrospective single-center cohort study derived from a prospective collected database, between 1 January 2009 and 2016. Multivariate logistic regression analysis was used to identify all significant predictive factors. Variables that were identified in the multivariate analysis were dichotomized at standard levels, and logistic regression was used for the analysis. To ensure that dichotomized variables were not overly simplistic, the C statistic was evaluated for both dichotomized and continuous models. Results: There were 500 patients with complete medical data included in the analysis during the study period. Of them, 37.6% were older than 74 years, and 83.8% were males. Multivariable logistic regression showed five variables that were predictive of mortality: age > 74 years (OR = 4.01, 95%CI 2.43−6.26), loss of consciousness (OR = 2.21, 95%CI 1.11−4.40), previous myocardial infarction (OR = 2.35, 95%CI 1.19−4.63), development of ventricular arrhythmia (OR = 4.54, 95%CI 1.75−11.78), and DAP < 60 mmHg (OR = 2.32, 95%CI 1.17−4.62). Assigning 1 point for each variable, patients were stratified according to the preoperative RAAA mortality risk score (range 0−5). Patients with 1 point suffered 15.3% mortality and 3 points 68.2% mortality, while all patients with 5 points died. Conclusions: This preoperative RAAA score identified risk factors readily assessed at the bedside and provides an accurate prediction of 30-day mortality after open repair of RAAA.

ANALYSIS OF SPIN IN VASCULAR SURGERY RANDOMIZED CONTROLLED TRIALS WITH NONSIGNIFICANT OUTCOMES

OBJECTIVES

Spin is the manipulation of language that distorts the interpretation of objective findings. The purpose of this study is to describe the characteristics of spin found in statistically nonsignificant randomized controlled trials (RCT) comparing carotid endarterectomy (CEA) to carotid artery stenting (CAS) for carotid stenosis (CS), and endovascular repair (EVAR) to open repair (OR) for abdominal aortic aneurysms (AAA).

METHODS

A search of MEDLINE, EMBASE, and the Cochrane Controlled Register of Trials was performed in June 2020 for studies published describing AAA or CS. All phase three RCTs with nonsignificant primary outcomes comparing OR to EVAR or CEA to CAS were included. Studies were appraised for the characteristics and severity of spin using a validated tool. Binary logistic regression was performed to assess the association of spin grade to (1) funding source (commercial vs non-commercial) and (2) the publishing journal's impact factor.

RESULTS

Thirty-one of 355 articles captured were included for analysis. Spin was identified in nine abstracts (9/18) and 13 main texts (13/18) of AAA articles and seven abstracts (7/13) and ten main texts (10/13) of CS articles. For both AAA and CS articles, spin was most commonly found in the manuscript discussion section, with the most commonly employed strategy being the interpretation of statistically nonsignificant primary results to show treatment equivalence or rule out adverse treatment effects. Increasing journal impact factor was associated with a statistically significant lower likelihood of spin in the study title or abstract conclusion (βOR = 0.96, 95% CI: 0.94 - 0.98, p < 0.01) while no significant association could be found with funding source (βOR = 1.33, 95% CI: 0.30-5.92, p = 0.71).

CONCLUSIONS

A large proportion of statistically nonsignificant RCTs contain interpretations that are inconsistent with their results. These findings should prompt authors and readers to appraise study findings independently and to limit the use of spin in study interpretations.

Endovascular aortic repair is a cost-effective option for in-hospital patients with abdominal aortic aneurysm

BACKGROUND

To investigate the cost-effectiveness of endovascular aortic repair (EVAR) versus open aortic repair (OAR) for abdominal aortic aneurysm (AAA) using incremental costs per decreased in-hospital mortality rate gained through our patients' cohort.

METHODS

Medical records and healthcare costs of patients with AAA hospitalized between 2010 and 2015 were extracted from the National Health Insurance Research Database (NHIRD) of Taiwan. Multiple regression analysis was applied to adjust for confounding factors and to compare the differences in postoperative clinical outcomes between patients who received EVAR and OAR. The incremental cost-effectiveness ratio (ICER) of EVAR was determined based on the healthcare cost obtained from the analyzed data.

RESULTS

A total of 2803 AAA patients were identified (n = 559 with ruptured AAA and n = 2244 unruptured AAA). Patients with ruptured AAA who underwent EVAR compared with OAR patients had shorter hospital and intensive care unit (ICU) stays (all p < 0.05). For patients with unruptured AAA, those who received EVAR compared with OAR, the adjusted odds ratio (aOR) of postoperative complications and in-hospital mortality were 0.371 and 0.447 (all p < 0.05). The total direct surgical costs and medical expenses during hospitalization in all AAA patients were higher for the EVAR group; however, ICER was <1 per capita gross domestic product. Stratification by age groups further suggested that ICER for patients with unruptured AAA who received EVAR, compared with OAR, decreased with age.

CONCLUSION

Total direct medical costs were higher for AAA patients receiving EVAR regardless of rupture status; however, the cost is offset by lower odds of postoperative complications and in-hospital mortality. The observed decrease in ICER with age and EVAR use warrants further analysis. Our findings further validate the use of EVAR over OAR. These results provides supporting evidence for physicians and patients with AAA to inform shared decision making regarding endovascular or OAR options.

Outcomes and predictors of mortality in a Belgian population of patients admitted with ruptured abdominal aortic aneurysm and treated by open repair in the contemporary era

BACKGROUND

Abdominal aortic aneurysm (AAA) rupture is a serious condition that results in extremely high mortality rates. Some improvements in outcome have been reported during the last 2 decades. The objective of the present study was to determine the overall and operative (by open repair) mortality related to ruptured AAA in the contemporary era and to identify preoperative, intraoperative, and early postoperative parameters associated with poor outcomes.

METHODS

We performed a retrospective review of all consecutive patients admitted to our single institution with a diagnosis of ruptured AAA between 2004 and 2013. A total of 103 parameters, including demographic characteristics, medical history, clinical and biological parameters, cardiovascular risk factors, emergency level, diagnostic modalities, time from symptoms to diagnosis and treatment, type of operative procedure and postoperative complications, were analyzed. The primary endpoint considered in this study was the cumulative incidence rate of mortality. The secondary endpoint was the identification, by logistic regression methods, of risk factors for overall mortality as well as for operative, and postoperative mortality.

RESULTS

Within our study period, 104 patients were admitted for a ruptured AAA. The majority of patients (84.6%) were male, and the AAA was known in 34.6% of the patients. Rupture occurred for a maximal diameter lower than 55 mm in 25% of the female population, compared to 5.7% of the male population (P = 0.030). The proportions of admitted patients who died before (preoperative mortality), during (intraoperative mortality) or after (postoperative hospital mortality) surgery was 17.3%, 16.3%, and 18.3%, respectively, yielding a cumulative in-hospital mortality of 51.9%. In the multivariate analysis, age ≥ 80 (P = 0.001), myocardial ischemia on the admission ECG (P = 0.046), and management by the physician response unit (P = 0.002) were the only preoperative parameters associated with a higher risk of hospital mortality. Four risk factors were found to be associated with a higher risk of postoperative mortality in the multivariate analysis, and all patients presenting with 3 or more of these risk factors (n = 5) died.

CONCLUSIONS

The overall mortality of ruptured AAA in a contemporary cohort of patients who underwent open repair remains high and does not seem to have decreased during recent decades. Ruptures occur at smaller diameters in women than in men, supporting a lower threshold for intervention in women with known AAA. We developed risk scores to predict the mortality of patients with rAAA at different times of their hospital course. The validity of these scores should be assessed in prospective clinical studies.

Association of Operative Repair Type and Trauma Center Designation With Outcomes in Ruptured Abdominal Aortic Aneurysm Repair

OBJECTIVE

Open repair of ruptured abdominal aortic aneurysm (rAAA) has shown improved outcomes at trauma centers. Whether the benefit of trauma center designation extends to endovascular repair of rAAA is unknown.

METHODS

Retrospective cohort study using the California Office of Statewide Health Planning and Development 2007 to 2014 discharge database to identify patients with rAAA. Data included demographic and admission factors, discharge disposition, International Classification of Diseases, Ninth Revision, Clinical Modification codes, and hospital characteristics. Hospitals were categorized by trauma center designation and teaching hospital status. The effect of repair type and trauma center designation (level I, level II, or other-other trauma centers and nondesignated hospitals) was evaluated to determine rates and risks of 9 postoperative complications, in-hospital mortality, and 30-day postdischarge mortality.

RESULTS

Of 1941 rAAA repair patients, 61.2% had open and 37.8% had endovascular; 1.0% had both. Endovascular repair increased over the study interval. Hospitals were 12.0% level I, 25.0% level II, and 63.0% other. A total of 48.7% of hospitals were teaching hospitals (level I, 100%; level II, 42.2%; and other, 41.8%). Endovascular repair was significantly more common at teaching hospitals (41.5% vs 34.3%, P < .001) and was the primary repair method at level I trauma centers (P < .001). Compared with open repair, endovascular repair was protective for most complications and in-hospital mortality. The risk for in-hospital mortality was highest among endovascular patients at level II trauma centers (hazard ratio 1.67, 95% confidence interval [CI]: 0.95-2.92) and other hospitals (hazard ratio 1.66, 95% CI: 1.01-2.72).

CONCLUSIONS

Endovascular repair overall was associated with a lower risk of adverse outcomes. Endovascular repair at level I trauma centers had a lower risk of in-hospital mortality which may be a result of their teaching hospital status, organizational structure, and other factors. The weight of the contributions of such factors warrants further study.

NHS hospital readiness to embrace the proposed NICE guidelines on abdominal aortic aneurysm: a public perspective

INTRODUCTION

The National Institute for Health and Care Excellence published a draft consultation update on abdominal aortic aneurysm, which was expected to be published on 7 November 2018. This article analyses the readiness of NHS hospitals and their workforce to embrace the proposed guidelines.

METHODS

The trust and individual surgeon-level anonymised data in the public domain for elective, rupture and complex abdominal aortic aneurysm cases were collected and analysed for all the acute care trusts providing these services from the Vascular Society of Great Briton and Ireland's prospective National Vascular Registry database.

RESULTS

Of the 95 acute care trusts providing the service for the year 2017, the annual volume of infrarenal abdominal aortic aneurysm (both endovascular and open repairs) ranged between 0 and 137. Of these, 64 (67.36%) trusts had an annual volume of fewer than 60 cases. A total of 366 (approximately 75% of 490) vascular surgeons have performed 10 or fewer open abdominal aortic aneurysm repairs in three years (2014-2016) with a mean operating volume of 1.452 procedures per surgeon per three years (n = 254, median 0, interquartile range, IQR, 0-3, 0.484 procedures per surgeon per year) and about 51% of the vascular surgeons have only performed five or fewer procedures in those three years with a mean operating volume of 3.455 per surgeon per three years (n = 367, median 3, IQR 0-3, 1.151 per surgeon per year).

CONCLUSION

The observations show that most UK acute hospitals lack the optimum case volume necessary to embrace the proposed change in the guideline.

Open Surgery for Ruptured Abdominal Aortic Aneurysm - 38 Years Experience at an Academic Center in Chile

BACKGROUND

Few series of ruptured abdominal aortic aneurysm (RAAA) from Latin America have been published.

OBJECTIVES

To report the outcomes of RAAA treated with open surgical repair (OSR) in a University Hospital in Chile. Secondary objectives are the identification of prognostic factors and survival rates.

METHODS

Retrospective review of consecutive RAAA patients treated with OSR between September 1979 and December 2017. Medical records, diagnostic images, and follow-up details were obtained. Statistical methods include multiple logistic regression analysis.

RESULTS

One hundred and sixteen patients underwent OSR for RAAA. The average age was 72.3 years (54-95), 62.9% ≥ 70 years, and 81.9% male. Preoperative systolic pressure <90 mm Hg was present in 74 patients (63.8%), and 10 (8.6%) experienced cardiac arrest before surgery. Only 30.2% were known to have an AAA before rupture. The mean aortic diameter was 7.9 cm. Sixteen patients had juxtarenal aneurysms (13.8%). The rupture was intra or retroperitoneal in 111 cases (95.7%), there were 4 fistulas to neighboring veins and one into the duodenum. Reconstruction included tubular graft in 39.7% and bifurcated in 58.6%. The estimated mean blood loss was 3,456 ± 2,768 mL (median 3,000). Mean mechanical ventilation was 7.4 ± 12.0 days and hemodialysis requirement in 21.8%. Six patients died during surgery and other 24 during the first postoperative month or in hospital, for an overall mortality rate of 25.9%. Age ≥70 years (P < 0.01), blood pressure less than 90 mm Hg (P = 0.03) and dialysis (P < 0.01) were associated with higher 30-day mortality rates. The survival rate was 68.0, 65.3, 44.3, and 25.2% at 1, 2, 5, and 10 years, respectively.

CONCLUSIONS

EVAR for RAAA is not affordable in every country. Outcomes of open RAAA repair at our institution are similar to results reported recently for OSR by the USA and European Medical centers.

Strategy of endovascular versus open repair for patients with clinical diagnosis of ruptured abdominal aortic aneurysm: the IMPROVE RCT

BACKGROUND

Ruptured abdominal aortic aneurysm (AAA) is a common vascular emergency. The mortality from emergency endovascular repair may be much lower than the 40-50% reported for open surgery.

OBJECTIVE

To assess whether or not a strategy of endovascular repair compared with open repair reduces 30-day and mid-term mortality (including costs and cost-effectiveness) among patients with a suspected ruptured AAA.

DESIGN

Randomised controlled trial, with computer-generated telephone randomisation of participants in a 1 : 1 ratio, using variable block size, stratified by centre and without blinding.

SETTING

Vascular centres in the UK (n = 29) and Canada (n = 1) between 2009 and 2013.

PARTICIPANTS

A total of 613 eligible participants (480 men) with a ruptured aneurysm, clinically diagnosed at the trial centre.

INTERVENTIONS

A total of 316 participants were randomised to the endovascular strategy group (immediate computerised tomography followed by endovascular repair if anatomically suitable or, if not suitable, open repair) and 297 were randomised to the open repair group (computerised tomography optional).

MAIN OUTCOME MEASURES

The primary outcome measure was 30-day mortality, with 30-day reinterventions, costs and disposal as early secondary outcome measures. Later outcome measures included 1- and 3-year mortality, reinterventions, quality of life (QoL) and cost-effectiveness.

RESULTS

The 30-day mortality was 35.4% in the endovascular strategy group and 37.4% in the open repair group [odds ratio (OR) 0.92, 95% confidence interval (CI) 0.66 to 1.28; p = 0.62, and, after adjustment for age, sex and Hardman index, OR 0.94, 95% CI 0.67 to 1.33]. The endovascular strategy appeared to be more effective in women than in men (interaction test p = 0.02). More discharges in the endovascular strategy group (94%) than in the open repair group (77%) were directly to home (p < 0.001). Average 30-day costs were similar between groups, with the mean difference in costs being -£1186 (95% CI -£2997 to £625), favouring the endovascular strategy group. After 1 year, survival and reintervention rates were similar in the two groups, QoL (at both 3 and 12 months) was higher in the endovascular strategy group and the mean cost difference was -£2329 (95% CI -£5489 to £922). At 3 years, mortality was 48% and 56% in the endovascular strategy group and open repair group, respectively (OR 0.73, 95% CI 0.53 to 1.00; p = 0.053), with a stronger benefit for the endovascular strategy in the subgroup of 502 participants in whom repair was started for a proven rupture (OR 0.62, 95% CI 0.43 to 0.89; p = 0.009), whereas aneurysm-related reintervention rates were non-significantly higher in this group. At 3 years, considering all participants, there was a mean difference of 0.174 quality-adjusted life-years (QALYs) (95% CI 0.002 to 0.353 QALYs) and, among the endovascular strategy group, a cost difference of -£2605 (95% CI -£5966 to £702), leading to 88% of estimates in the cost-effectiveness plane being in the quadrant showing the endovascular strategy to be 'dominant'.

LIMITATIONS

Because of the pragmatic design of this trial, 33 participants in the endovascular strategy group and 26 in the open repair group breached randomisation allocation.

CONCLUSIONS

The endovascular strategy was not associated with a significant reduction in either 30-day mortality or cost but was associated with faster participant recovery. By 3 years, the endovascular strategy showed a survival and QALY gain and was highly likely to be cost-effective. Future research could include improving resuscitation for older persons with circulatory collapse, the impact of local anaesthesia and emergency consent procedures.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN48334791 and NCT00746122.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 31. See the NIHR Journals Library website for further project information.

Claims Variability in Charges and Payments for Common Open and Endovascular Procedures

BACKGROUND

Cost-effectiveness in healthcare is being increasingly scrutinized. Data regarding claims variability for vascular operations are lacking. Herein, we aim to describe variability in charges and payments for aortoiliac (AI) and infrainguinal (II) revascularizations.

METHODS

We analyzed 2012-2014 claims data from a statewide claims database for procedures grouped by Current Procedural Terminology codes into II-open (II-O), II-endovascular (II-E), AI-open (AI-O), and AI-endovascular interventions (AI-E). We compared charges and payments in urban (≥50,000 people, UAs) versus rural areas (<50,000 people, RAs). Amounts are reported in $US as median with interquartile range. Cost-to-charge ratios (CCRs) as a measure of reimbursement were calculated as the percentage of the charges covered by the payments. Wilcoxon rank-sum tests were performed to determine significant differences.

RESULTS

A total of 5,239 persons had complete claims data. There were 7,239 UA and 6,891 RA claims, and 1,057 AI claims (AI-E = 879, AI-O = 178) and 4,182 II claims (II-E = 3,012, II-0 = 1,170). Median charges were $5,357 for AI [$1,846-$27,107] and $2,955 for II [$1,484-$9,338.5] (P < 0.0001). Median plan payment was $454 for AI [$0-$1,380] and $454 for II [$54-$1,060] (P = 0.67). For AI and II, charges were significantly higher for UA than RA (AI: UA $9,875 [$2,489-$34,427], RA $3,732 [$1,450-$20,595], P < 0.0001; II: UA $3,596 [$1,700-$21,664], RA $2,534 [$1,298-$6,169], P < 0.0001). AI-E charges were higher than AI-O (AI-E $7,960 [$1,699-$32,507], AI-O $4,774 [$2,636-$7,147], P < 0.0001), but AI-O payments were higher (AI-E $424 [$0-$1,270], AI-O $869 [$164-$1,435], P = 0.0067). II-E charges were higher (II-E $2,994 [$1,552-$22,164], II-O $2,873 [$1,108-$5,345], P < 0.0001), but II-O payments were higher (II-E $427 [$50-$907], II-O $596 [$73-$1,299], P < 0.0001). CCRs were highest for II operations and UAs.

CONCLUSIONS

Wide variability in claim charges and payments exists for vascular operations. AI procedures had higher charges than II, without any difference in payments. UA charged more than RA for both AI and II operations, but RA had higher payments and CCRs. Endovascular procedures had higher charges, while open procedures had higher payments. Charge differences may be related to endovascular device costs, and further research is necessary to determine the reasons behind consistent claims variability between UA and RA.

Long-term outcome and quality of life after ruptured abdominal aortic aneurysm repair

Objectives

To evaluate long-term outcome and quality of life after open and endovascular repair of ruptured abdominal aortic aneurysms.

Methods

All consecutive ruptured abdominal aortic aneurysm patients at the St. Antonius Hospital treated for ruptured abdominal aortic aneurysm between January 2005 and January 2015 were included. Mortality, morbidity, and re-interventions within 30 days and during follow-up were registered. Quality of life was measured with Short Form-36 questionnaire among survivors. Additional subgroup analysis between open repair and endovascular repair was performed.

Results

A total of 192 patients with ruptured abdominal aortic aneurysm were included: 76.6% (147/192) underwent open repair and 23.4% (45/192) endovascular repair. All-cause 30-day mortality rate was 31.3% (60/192), and 30-day morbidity rate was 70.3% (135/192). Median stay at the intensive care unit was two days for endovascular repair and four days for open repair ( p = 0.002). No other statistically significant differences between endovascular repair and open repair were observed. After a mean follow-up period of 62 months (range 9–126), 72.4% (76/105) of the responders had equivalent Short Form-36 scores as compared to the age-matched general Dutch population, and 84.2% (64/76) of the responders would choose surgery again if they would have a ruptured abdominal aortic aneurysm.

Conclusions

Survivors of ruptured abdominal aortic aneurysm have similar long-term quality of life scores compared to the age-matched general population. The majority of all survivors would choose to undergo acute abdominal aortic aneurysm repair again.

Endovascular treatment for ruptured abdominal aortic aneurysm

BACKGROUND

An abdominal aortic aneurysm (AAA) (pathological enlargement of the aorta) is a condition that can occur as a person ages. It is most commonly seen in men older than 65 years of age. Progressive aneurysm enlargement can lead to rupture and massive internal bleeding, which is fatal unless timely repair can be achieved. Despite improvements in perioperative care, mortality remains high (approximately 50%) after conventional open surgical repair. Endovascular aneurysm repair (EVAR), a minimally invasive technique, has been shown to reduce early morbidity and mortality as compared to conventional open surgery for planned AAA repair. More recently emergency endovascular aneurysm repair (eEVAR) has been used successfully to treat ruptured abdominal aortic aneurysm (RAAA), proving that it is feasible in select patients; however, it is unclear if eEVAR will lead to significant improvements in outcomes for these patients or if indeed it can replace conventional open repair as the preferred treatment for this lethal condition. This is an update of the review first published in 2006.

OBJECTIVES

To assess the advantages and disadvantages of emergency endovascular aneurysm repair (eEVAR) in comparison with conventional open surgical repair for the treatment of ruptured abdominal aortic aneurysm (RAAA). This will be determined by comparing the effects of eEVAR and conventional open surgical repair on short-term mortality, major complication rates, aneurysm exclusion (specifically endoleaks in the eEVAR treatment group), and late complications.

SEARCH METHODS

For this update the Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register (last searched June 2016), CENTRAL (2016, Issue 5), and trials registries. We also checked reference lists of relevant publications.

SELECTION CRITERIA

Randomised controlled trials in which participants with a clinically or radiologically diagnosed RAAA were randomly allocated to eEVAR or conventional open surgical repair.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies identified for potential inclusion for eligibility. Two review authors also independently completed data extraction and quality assessment. Disagreements were resolved through discussion. We performed meta-analysis using fixed-effect models with odds ratios (ORs) and 95% confidence intervals (CIs) for dichotomous data and mean differences with 95% CIs for continuous data.

MAIN RESULTS

We included four randomised controlled trials in this review. A total of 868 participants with a clinical or radiological diagnosis of RAAA were randomised to receive either eEVAR or open surgical repair. Overall risk of bias was low, but we considered one study that performed randomisation in blocks by week and performed no allocation concealment and no blinding to be at high risk of selection bias. Another study did not adequately report random sequence generation, putting it at risk of selection bias, and two studies were underpowered. There was no clear evidence to support a difference between the two interventions for 30-day (or in-hospital) mortality (OR 0.88, 95% CI 0.66 to 1.16; moderate-quality evidence). There were a total of 44 endoleak events in 128 participants from three studies (low-quality evidence). Thirty-day complication outcomes (myocardial infarction, stroke, composite cardiac complications, renal complications, severe bowel ischaemia, spinal cord ischaemia, reoperation, amputation, and respiratory failure) were reported in between one and three studies, therefore we were unable to draw a robust conclusion. We downgraded the quality of the evidence for myocardial infarction, renal complications, and respiratory failure due to imprecision, inconsistency, and risk of bias. Odds ratios for complications outcomes were OR 2.38 (95% CI 0.34 to 16.53; 139 participants; 2 studies; low-quality evidence) for myocardial infarction; OR 1.07 (95% CI 0.21 to 5.42; 255 participants; 3 studies; low-quality evidence) for renal complications; and OR 3.62 (95% CI 0.14 to 95.78; 32 participants; 1 study; low-quality evidence) for respiratory failure. There was low-quality evidence of a reduction in bowel ischaemia in the eEVAR treatment group, but very few events were reported (OR 0.37, 95% CI 0.14 to 0.94), and we downgraded the evidence due to imprecision and risk of bias. Six-month and one-year outcomes were evaluated in three studies, but only results from a single study could be used for each outcome, which showed no clear evidence of a difference between the interventions. We rated six-month mortality evidence as of moderate quality due to imprecision (OR 0.89, 95% CI 0.40 to 1.98; 116 participants).

AUTHORS' CONCLUSIONS

The conclusions of this review are currently limited by the paucity of data. We found from the data available moderate-quality evidence suggesting there is no difference in 30-day mortality between eEVAR and open repair. Not enough information was provided for complications for us to make a well-informed conclusion, although it is possible that eEVAR is associated with a reduction in bowel ischaemia. Long-term data were lacking for both survival and late complications. More high-quality randomised controlled trials comparing eEVAR and open repair for the treatment of RAAA are needed to better understand if one method is superior to the other, or if there is no difference between the methods on relevant outcomes.

Ruptured abdominal aortic aneurysm: Is endovascular aneurysm repair the answer for everybody?

Treatment paradigms for elective repair of asymptomatic abdominal aortic aneurysms (AAA) have evolved during the past 2 decades, with endovascular aneurysm repair as the preferred treatment modality. The patient care strategy for emergent treatment for ruptured AAA is not as straightforward, due in part to surgeon expertise and stent-graft availability at the institution. Although most reports have extrapolated elective endovascular aneurysm repair feasibility data to the ruptured AAA patient and the aneurysm anatomy, these expectations should be interpreted with caution. In the absence of level I evidence, and lack of adequate local hospital resources, endovascular aneurysm repair-first policy might not be feasible for all the patients who present with ruptured AAA.

Extended use of endovascular aneurysm sealing for ruptured abdominal aortic aneurysms

Endovascular repair of abdominal aortic aneurysms (EVAR) is now an established treatment modality for suitable patients presenting with aneurysm rupture. EVAR for ruptured aneurysms reduces transfusion, mechanical ventilation, intensive care. and hospital stay when compared with open surgery. In the emergency setting, however, EVAR is limited by low applicability due to adverse clinical or anatomical characteristics and increased need for reintervention. In addition, ongoing bleeding from aortic side branches post-EVAR can cause hemodynamic instability, larger hematomas, and abdominal compartment syndrome. Endovascular aneurysm sealing, based on polymer filling of the aneurysm, has the potential to overcome some of the limitations of EVAR for ruptured aneurysms and to improve outcomes. Recent literature suggests that endovascular aneurysm sealing can be performed with early mortality similar to that of EVAR for ruptured aortic aneurysms, but experience is limited to a few centers and a small number of patients. The addition of chimney grafts can increase the applicability of endovascular aneurysm sealing in order to treat short-neck and juxtarenal aneurysms as an alternative to fenestrated endografts. Further evaluation of the technique, with larger longitudinal studies, is necessary before advocating wider implementation of endovascular aneurysm sealing in the emergency setting.

Endovascular Repair for Ruptured Abdominal Aortic Aneurysms has Improved Outcomes Compared to Open Surgical Repair

INTRODUCTION

Ruptured abdominal aortic aneurysm (rAAA) remains a critical diagnosis, and research is needed to address outcomes following surgical repair. The purpose of this study was to compare nationwide outcomes for patients who received either endovascular repair (EVAR) or open surgical repair (OSAR) for rAAA.

METHODS

The Medicare Provider Analysis and Review file from 2005 to 2009 was used to identify patients diagnosed with rAAA and treated with either EVAR or OSAR. Those patients with both procedures were excluded. Primary outcomes included mortality, postoperative complications, and readmission rates. Secondary outcomes included hospital resource utilization and length of stay (LOS).

RESULTS

A total of 8480 patients with rAAA who underwent EVAR (n = 1939) or OSAR (n = 6541) were identified. On multivariate regression, the likelihood of dying in the hospital after OSAR compared to EVAR was significantly greater (odds ratio [OR] = 1.95; 95% confidence interval [CI] = 1.74-2.18). There was significantly greater frequency of postoperative complications after OSAR compared to EVAR (OR = 2.1, 95%CI = 1.86-2.37, P < .0001). Freedom from readmission after OSAR was significantly greater than that after EVAR. Total hospital cost for all services after EVAR was greater than that after OSAR (US$100 875 vs US$89 035; P < .0001), but intensive care unit (ICU) cost for EVAR was significantly less than that for OSAR (US$5516 vs US$8600; P < .0001). Total hospital and ICU LOS were shorter in EVAR compared to OSAR (P < .0001 for both).

DISCUSSION

EVAR for rAAA has shown mortality benefits over OSAR as well as reduced ICU and total LOS. This data suggest EVAR is associated with a greater survival benefit, fewer postoperative complications, and may help improve hospital resource utilization.

Improved trends in patient survival and decreased major complications after emergency ruptured abdominal aortic aneurysm repair

BACKGROUND

Improved trends in patient survival and decreased major complications after emergency ruptured abdominal aortic aneurysm (AAA) repair. Emergency AAA repair carries a high risk of morbidity and mortality. This study seeks to examine morbidity and mortality trends from the National Surgical Quality Improvement Program (NSQIP) database, and identify potential risk factors.

METHODS

All emergency AAA repairs were identified using the NSQIP database from 2005 to 2011. Univariate analysis (using the Student t, χ(2), and Fisher's exact tests) and multivariate logistic regression was performed to examine trends in mortality and morbidity.

RESULTS

Out of 2761 patients who underwent emergency AAA repair, 321 (11.6%) died within 24 hours of surgery. Of the remaining 2440 patients, 1133 (46.4%) experienced major complications and 459 (18.8%) died during the postoperative period. From 2005 to 2011, there was a significant decrease in patient mortality, particularly in patients who survived the perioperative period (P = .002). Total complications increased overall (P < .0001); however, major complications decreased from 58.7% in 2005 to 42.6% in 2011 (P < .0001) among patients who survived beyond 24 hours. The use of endovascular aortic repair (EVAR) increased over the study period (P < .0001). On multivariate analysis of patients who survived past the initial 24-hour period, advancing age (odds ratio [OR], 1.1; 95% confidence interval [CI], 1.0-1.1), chronic obstructive pulmonary disease (OR, 2.6; 95% CI, 1.7-4.1), dependent functional status (OR, 2.0; 95% CI, 1.2-3.2), and presence of a major complication (OR, 3.1; 95% CI, 2.0-5.0) were significantly associated with death, whereas presence of a senior resident (OR, 0.4; 95% CI, 0.3-0.6) or fellow (OR 0.3; 95% CI, 0.2-0.6) was inversely associated with death. EVAR was not associated with death, but was associated with 30-day complications (OR, 0.5; 95% CI, 0.3-0.6).

CONCLUSIONS

Patient survival has increased from 2005 to 2011 after emergency AAA repair, with a significant improvement particularly in patients who survive past the first 24 hours. EVAR was not associated with mortality, but was protective of 30-day complications. Although the total number of complications increased, the number of major complications decreased over the study period, suggesting that newer techniques and patient care protocols may be improving outcomes.

Endovascular Versus Open Repair as Primary Strategy for Ruptured Abdominal Aortic Aneurysm: A National Population-based Study

OBJECTIVE/BACKGROUND

In randomized trials, no peri-operative survival benefit has been shown for endovascular (EVAR) repair of ruptured abdominal aortic aneurysm (rAAA) when compared with open repair. The aim of this study was to investigate the effect of primary repair strategy on early and midterm survival in a non-selected population based study.

METHODS

The Swedish Vascular Registry was consulted to identify all rAAA repairs performed in Sweden in the period 2008-12. Centers with a primary EVAR strategy (treating > 50% of rAAA with EVAR) were compared with centers with a primary open repair strategy. Peri-operative outcome, midterm survival, and incidence of rAAA repair/100,000 inhabitants aged > 50 years were assessed.

RESULTS

In total, 1,304 patients were identified. Three primary EVAR centers (pEVARc) operated on 236 patients (74.6% EVAR). Twenty-six primary open repair centers (pORc) operated 1,068 patients (15.6% EVAR). Patients treated at pEVARc were more often referrals (28.0% vs. 5.3%; p < .01), had a higher rate of respiratory comorbidity (36.5% vs. 21.9%; p < .01), and higher pre-operative systolic blood pressure (84.3 vs. 72.3 mmHg; p < .01). There was no difference in mortality based on primary treatment strategy at 30 days (pEVARc 28.0%, n = 66; pORc 27.4%, n = 296 [p = .87]), 1 year (pEVARc 39.9%, n = 93; pORc 34.7%, n = 366 [p = .19]), or 2 years (42.1%, n = 94; 38.3%, n = 394 [p = .28]), either overall or in subgroups based on age or referral status. Overall, patients treated with EVAR were older (mean age 76.4 vs. 74.0 years; p < .01), and had a lower 30 day mortality (EVAR 21.6%, n = 74; odds ratio 29.6%, n = 288 [p = < .01]). Incidence of rAAA repair was lower in pEVARc regions (6.07, 95% confidence interval [CI] 5.01-7.13) when compared with pORc regions (8.15, 95% CI 7.64-8.66).

CONCLUSION

There was no difference in mortality after rAAA repair among centers with a primary EVAR approach when compared with a primary open repair strategy, either peri-operatively or in the midterm. The study supports the early findings of the randomized controlled trials in a national population based setting.

Endovascular strategy or open repair for ruptured abdominal aortic aneurysm: one-year outcomes from the IMPROVE randomized trial

Aims

To report the longer term outcomes following either a strategy of endovascular repair first or open repair of ruptured abdominal aortic aneurysm, which are necessary for both patient and clinical decision-making.

Methods and results

This pragmatic multicentre (29 UK and 1 Canada) trial randomized 613 patients with a clinical diagnosis of ruptured aneurysm; 316 to an endovascular first strategy (if aortic morphology is suitable, open repair if not) and 297 to open repair. The principal 1-year outcome was mortality; secondary outcomes were re-interventions, hospital discharge, health-related quality-of-life (QoL) (EQ-5D), costs, Quality-Adjusted-Life-Years (QALYs), and cost-effectiveness [incremental net benefit (INB)]. At 1 year, all-cause mortality was 41.1% for the endovascular strategy group and 45.1% for the open repair group, odds ratio 0.85 [95% confidence interval (CI) 0.62, 1.17], P = 0.325, with similar re-intervention rates in each group. The endovascular strategy group and open repair groups had average total hospital stays of 17 and 26 days, respectively, P < 0.001. Patients surviving rupture had higher average EQ-5D utility scores in the endovascular strategy vs. open repair groups, mean differences 0.087 (95% CI 0.017, 0.158), 0.068 (95% CI −0.004, 0.140) at 3 and 12 months, respectively. There were indications that QALYs were higher and costs lower for the endovascular first strategy, combining to give an INB of £3877 (95% CI £253, £7408) or €4356 (95% CI €284, €8323).

Conclusion

An endovascular first strategy for management of ruptured aneurysms does not offer a survival benefit over 1 year but offers patients faster discharge with better QoL and is cost-effective.

Clinical trial registration

ISRCTN 48334791.

Midterm Re-interventions and Survival After Endovascular Versus Open Repair for Ruptured Abdominal Aortic Aneurysm

OBJECTIVE

To compare the midterm re-intervention and survival rates after EVAR and OR for ruptured abdominal aortic aneurysms (RAAA).

METHODS

Observational cohort study including all consecutive RAAA patients between 2004 and 2011 in 10 hospitals in the Amsterdam ambulance region. The primary end point was re-interventions within 5 years of the primary intervention. The secondary end point was death. The outcomes were estimated by survival analyses, compared using the logrank test, and subsequently adjusted for possible confounders using Cox proportional hazard models. Re-interventions were estimated in all patients and in patients who survived their hospital stay.

RESULTS

Of 467 patients with a RAAA, 73 were treated by EVAR and 394 by OR. Five years after the primary intervention, the rates of freedom from re-intervention were 55% for EVAR (26/73, 95% CI: 41-69%) and 60% for OR (130/394, 95% CI: 55-66%) (p = .96). After adjustment for age, sex, comorbidity, and pre-operative hemodynamic stability, the risk of re-intervention was similar (HR 1.01, 95% CI: 0.65-1.55). The survival rates were 36% for EVAR (45/73, 95% CI: 24-47%) and 38% for OR (235/394, 95% CI: 33-43%) (p = .83). In 297 patients who survived their hospital stay, the rates of freedom from re-intervention were 66% for EVAR (15/54, 95% CI: 52-81%) and 90% for OR (20/243, 95% CI: 86-95%) (p < .01). After adjustment for age and sex, the risk of re-intervention was higher after EVAR (HR 0.27, 95% CI: 0.14-0.52).

CONCLUSIONS

Five years after the primary intervention, endovascular and open repair for ruptured abdominal aortic aneurysm resulted in similar re-intervention and survival rates. However, in patients who survived their hospital stay the re-intervention rate was higher for EVAR than for OR.