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McClure RS, Rommens KL, Herget EJ, Keir M, Gregory AJ, Smith HN, Moore RD. The Aortic Team Model for the Management of the Distal Arch, Descending Thoracic and Thoracoabdominal Aorta: Appraisal at 3 Years. AORTA (STAMFORD, CONN.) 2024. [PMID: 38698622 DOI: 10.1055/s-0044-1779249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2024]
Abstract
BACKGROUND This study aimed to assess feasibility, logistical challenges, and clinical outcomes associated with the implementation of an Aortic Team model for the management of distal arch, descending thoracic and thoracoabdominal aortic disease. METHODS An Aortic Team care pathway was implemented in November 2019. Working as a unit, two cardiac surgeons, two vascular surgeons, an interventional radiologist, a cardiologist, and an anesthesiologist collectively determined care decisions via multispecialty presence at an Aortic Clinic. Cardiac and vascular surgeons operated in tandem for open procedures. Interventional radiology participated alongside cardiac and vascular for endovascular procedures. Cardiology aided in medical therapies for heritable and degenerative disease, and had a lead role for genetics and high-risk pregnancy referrals. The model spanned three hospitals. Clinical outcomes at 3 years were assessed. RESULTS There were 35 descending thoracic and thoracoabdominal surgeries and 77 thoracic endovascular aortic repairs. Endoarch devices were used in 7 cases (Gore Thoracic Branch Endoprosthesis, 4, Terumo RelayBranch, 3) and an endothoracoabdominal device in 4 cases (Cook Zenith t-branch). The Aortic Clinic acquired 456 patients, with yearly increases (54 patients [year 1], 181 patients [year 2], 221 patients [year 3]). For surgery, mortality was 8.6% (3/35), permanent paralysis 5.7% (2/35), stroke 8.6% (3/35), permanent dialysis 0%, and reinterventions 8.6% (3/35). For endovascular cases, mortality was 3.9% (3/77), permanent paralysis 3.9% (3/77), stroke 5.2% (4/77), permanent dialysis 1.3% (1/77), and reinterventions 16.9% (13/77). CONCLUSION An Aortic Team model is feasible and ensures all treatment options are considered. Conventional open thoracoabdominal procedures showed acceptable outcomes. Endoarch technology shows early promise.
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Affiliation(s)
- R Scott McClure
- Division of Cardiac Surgery, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Kenton L Rommens
- Division of Vascular Surgery, Department of Surgery, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Eric J Herget
- Division of Interventional Radiology, Department of Diagnostic Imaging, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Michelle Keir
- Division of Cardiology, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Alex J Gregory
- Department of Anesthesia, Perioperative and Pain Medicine, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Holly N Smith
- Division of Cardiac Surgery, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Randy D Moore
- Division of Vascular Surgery, Department of Surgery, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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McClure RS, Lindsay TF, Keir M, Bayne JP, Berry RF, Chu MWA, Chung JCY, Dagenais F, Ducas RA, Duncan A, Horne G, Klass D, Mongeon FP, Richer J, Rommens KL. The Aortic Team Model and Collaborative Decision Pathways for the Management of Complex Aortic Disease: Clinical Practice Update From the Canadian Cardiovascular Society/Canadian Society of Cardiac Surgeons/Canadian Society for Vascular Surgery/Canadian Association for Interventional Radiology. Can J Cardiol 2023; 39:1484-1498. [PMID: 37949520 DOI: 10.1016/j.cjca.2023.07.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 07/30/2023] [Accepted: 07/31/2023] [Indexed: 11/12/2023] Open
Abstract
Disease of the aortic arch, descending thoracic, or thoracoabdominal aorta necessitates dedicated expertise across medical, endovascular, and surgical specialties. Cardiologists, cardiac surgeons, vascular surgeons, interventional radiologists, and others have expertise and skills that aid in the management of patients with complex aortic disease. No specialty is uniformly expert in all aspects of required care. Because of this dispersion of expertise across specialties, an aortic team model approach to decision-making and treatment is advocated. A nonhierarchical partnership across specialties within an interdisciplinary aortic clinic ensures that all treatment options are considered and promotes shared decision-making between the patient and all aortic experts. Furthermore, regionalization of care for aortic disease of increased complexity assures that the breadth of treatment options is available and that favourable volume-outcome ratios for high-risk procedures are maintained. An awareness of best practice care pathways for patient referrals for preventative management, acute care scenarios, chronic care scenarios, and pregnancy might facilitate a more organized management schema for aortic disease across Canada and improve lifelong surveillance initiatives.
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Affiliation(s)
- R Scott McClure
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada.
| | - Thomas F Lindsay
- Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Michelle Keir
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Jason P Bayne
- Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Robert F Berry
- QEII Health Sciences Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Michael W A Chu
- London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Jennifer C-Y Chung
- Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Francois Dagenais
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Quebec City, Quebec, Canada
| | - Robin A Ducas
- St Boniface Hospital, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Audra Duncan
- London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Gabrielle Horne
- QEII Health Sciences Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Darren Klass
- Vancouver Coastal Health, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Julie Richer
- University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Kenton L Rommens
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
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Outcomes of intact thoracic endovascular aortic repair in octogenarians. J Vasc Surg 2021; 74:882-892.e1. [PMID: 33600927 DOI: 10.1016/j.jvs.2021.01.039] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 01/03/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Thoracic endovascular aortic repair (TEVAR) is a suitable alternative to open aortic surgery especially for older patients with poor general health and functional status. However, data on the benefit of TEVAR in elderly patients are limited. The aim of this study was to use a large national database to compare the outcomes of TEVAR in octogenarians vs nonoctogenarians in the treatment of thoracic aortic aneurysms and dissection. METHODS All patients who underwent TEVAR for nonruptured thoracic aneurysms or dissection (zones 1-5) between January 2014 and February 2019 were identified in the Vascular Quality Initiative database. The primary outcome was in-hospital mortality. Secondary outcomes included cardiac adverse events; neurologic events; respiratory complications; new-onset dialysis; leg compartment syndrome; postoperative hematoma in addition to spinal, bowel, arm, and leg emboli/ischemia; and return to the operating room. Outcomes were compared between octogenarians (age ≥80 years) and nonoctogenarians (age <80 years) using univariable and multivariable logistic regression models. RESULTS A total of 2042 patients were identified, including 390 octogenarians (19.1%). Compared with nonoctogenarians, octogenarians had higher percentages of females (49.5% vs 40.4%; P < .01) and White patients (75.9% vs 68.6%; P < .01) and were more likely to present with thoracic aneurysms (86.2% vs 64.3%; P < .001). They also had larger aortic diameters (maximum diameter, 60.3 ± 15.8 mm vs 53.4 ± 17.4 mm), less proximal disease zones (zone 1, 3.3% vs 5.5%; zone 2, 13.9% vs 24.1%; P < .001) and were more likely to undergo the procedure under local/regional anesthesia (5.4% vs 2.4%; P < .01) compared with patients less than 80 years of age. No association was observed between octogenarians and in-hospital mortality after TEVAR for aneurysms (5.1% vs 3.3%; odds ratio [OR], 1.38; 95% confidence interval [CI], 0.72-2.61; P = .33) or dissection (5.6% vs 4.9%; OR, 0.68; 95% CI, 0.14-3.32; P = .63). However, for thoracic aneurysm repair, octogenarians had a 44% higher adjusted odds of in-hospital complications (27.4% vs 20.7%; OR, 1.44; 95% CI, 1.04-1.98; P = .03) compared with their younger counterparts. In-hospital complications (27.8% vs 26.2%; P = .79; OR, 1.02; 95% CI, 0.50-2.11; P = .95) were similar in octogenarians undergoing endovascular repair for dissections of the thoracic aorta. Octogenarians were also associated with 1.74 times the mortality hazard compared with nonoctogenarians (adjusted hazard ratio, 1.74; 95% CI, 1.18-2.58; P = .01). CONCLUSIONS TEVAR is an acceptable treatment option for octogenarians who have aortic arch and descending aortic aneurysms or dissections (zones 1-5). However, in case of aneurysms, they might be at a higher risk of in-hospital complications. Octogenarians also had increased hazard of 1-year mortality; however, the exact cause of this mortality could not be deciphered. Our findings suggest that elderly patients should not be denied TEVAR based on age if they are medically and anatomically fit for this procedure.
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McClure RS, Berry RF, Dagenais F, Forbes TL, Grewal J, Keir M, Klass D, Kotha VK, McMurtry MS, Moore RD, Payne D, Rommens K. The Many Care Models to Treat Thoracic Aortic Disease in Canada: A Nationwide Survey of Cardiac Surgeons, Cardiologists, Interventional Radiologists, and Vascular Surgeons. CJC Open 2021; 3:787-800. [PMID: 34169258 PMCID: PMC8209400 DOI: 10.1016/j.cjco.2021.02.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 02/01/2021] [Indexed: 11/30/2022] Open
Abstract
Background Several specialties treat thoracic aortic disease, resulting in multiple patient care pathways. This study aimed to characterize these varied care models to guide health policy. Methods A 57-question e-survey was sent to staff cardiac surgeons, cardiologists, interventional radiologists, and vascular surgeons at 7 Canadian medical societies. Results For 914 physicians, the response rate was 76% (86 of 113) for cardiac surgeons, 40% (58 of 146) for vascular surgeons, 24% (34 of 140) for radiologists, and 14% (70 of 515) for cardiologists. Several services admitted type B dissections (vascular 37%, cardiology 31%, cardiac 18%, other 7%), and care was heterogeneous. Ownership of disease management was overestimated relative to the perspective of the other specialties. Type A dissection admissions and treatment were more uniform, but emergent call coverage varied. A 24/7 aortic specialist on-call schedule was present only 4% of the time. “Aortic” case rounds promoted attendance by a broader aortic specialty contingency relative to rounds that were specialty specific. Although 89% of respondents felt an aortic team was best for patient care, only 54% worked at an institution with an aortic team present, and only 28% utilized an aortic clinic. Questions designed to define an aortic team derived 63 different combinations. Conclusions Thoracic aortic disease follows a network of undefined and variable care pathways, despite its high-risk population in need of complex treatment considerations. Multidisciplinary aortic teams and clinics exist in low volume, and the “aortic team” remains an obscure construct. A multispecialty initiative to define the aortic team and outline standardized navigation pathways within the health systems hospitals is advocated.
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Affiliation(s)
- R Scott McClure
- Department of Cardiac Sciences, Division of Cardiac Surgery, Libin Cardiovascular Institute, Foothills Medical Centre, University of Calgary, Calgary, Alberta, Canada
| | - Robert F Berry
- Department of Diagnostic Radiology, Division of Interventional Radiology, Queen Elizabeth II Health Sciences Centre, Victoria General Hospital, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Francois Dagenais
- Department of Cardiac Surgery, Institut Universitaire de Cardiology et Pneumologie de Québec, Québec City, Québec, Canada
| | - Thomas L Forbes
- Department of Surgery, Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Jasmine Grewal
- Department of Medicine, Division of Cardiology, St Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Michelle Keir
- Department of Cardiac Sciences, Division of Cardiology, Libin Cardiovascular Institute, Southern Alberta Adult Congenital Heart Clinic, University of Calgary, Calgary, Alberta, Canada
| | - Darren Klass
- Department of Diagnostic Radiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Vamshi K Kotha
- Department of Diagnostic Imaging, Division of Interventional Radiology, Foothills Medical Centre, University of Calgary, Calgary, Alberta, Canada
| | - M Sean McMurtry
- Department of Medicine, Division of Cardiology, University of Alberta Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Randy D Moore
- Department of Surgery, Division of Vascular Surgery, Libin Cardiovascular Institute, Peter Lougheed Centre, University of Calgary, Calgary, Alberta Canada
| | - Darrin Payne
- Department of Surgery, Division of Cardiac Surgery, Kingston General Hospital, Queen's University, Kingston, Ontario, Canada
| | - Kenton Rommens
- Department of Surgery, Division of Vascular Surgery, Libin Cardiovascular Institute, Peter Lougheed Centre, University of Calgary, Calgary, Alberta Canada
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Acheampong DO, Paul P, Boateng P, Leitman IM. Predictors and Outcomes of Cardiac Events following Thoracic Endovascular Aortic Repair in Descending Thoracic Aortic Aneurysm and Dissection. AORTA : OFFICIAL JOURNAL OF THE AORTIC INSTITUTE AT YALE-NEW HAVEN HOSPITAL 2020; 8:6-13. [PMID: 32599627 PMCID: PMC7324254 DOI: 10.1055/s-0040-1701606] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Cardiac events following thoracic endovascular aortic repair (TEVAR) have been associated with significant morbidity and mortality. However, predictors of post-TEVAR cardiac events in descending thoracic aortic aneurysm or dissection are poorly understood. METHODS A retrospective analysis of completed TEVAR procedures performed from 2010 to 2016 was conducted using the ACS-NSQIP (American College of Surgeons National Surgical Quality Improvement Program) participant user file database. Adult patients (≥18 years) who underwent TEVAR for descending thoracic aortic aneurysm or dissection were identified and 30-day outcomes were examined. An initial univariate analysis was performed to determine associations between all patient variables and cardiac events, defined as myocardial infarction or cardiac arrest that occurred ≤30 days of surgery. Multivariate logistic regression was subsequently performed to identify independent risk factors for cardiac events following TEVAR. RESULTS The study identified 150 out of 2,905 (5.2%) patients who underwent TEVAR for descending thoracic aortic aneurysm or dissection who developed cardiac events. No significant difference in incidence of cardiac events was noted among patients presenting with aortic aneurysm or dissection (p = 0.339). The overall 30-day mortality rate for all patients was 9.1%. Independent preoperative predictors of post-TEVAR cardiac events included emergency procedure (odds ratio [OR] 2.80, 95% confidence interval [CI] 1.9-4.1, p < 0.01); American Society of Anesthesiologists score >3 (OR 1.71, 95% CI 1.1-2.6, p = 0.01), ventilator dependence (OR 2.33, 95% CI 1.3-4.2, p < 0.01), renal failure (OR 2.53, 95% CI 1.50-4.3, p < 0.01), blood transfusion (OR 1.84, 95% CI 1.1-3.2, p = 0.03), and preoperative leukocytosis (OR 2.45, 1.6-3.8, p < 0.01). After TEVAR, unplanned reintubation (OR 5.52, 95% CI 3.5-8.8, p < 0.01), prolonged mechanical ventilation (OR 1.94, 95% CI 1.2-3.2, p = 0.011), and postoperative blood transfusion (OR 4.02, 95% CI 2.70-6.0, p < 0.01) were independent predictors of cardiac events. Cardiac events greatly increased mortality (60.7 vs. 5.5%), total length of hospital stay (13.2 ± 14.7 days vs. 8.3 ± 9.3 days), and readmission rates (19.3 vs. 8.2%, p < 0.01). CONCLUSIONS Cardiac events following TEVAR are associated with significant mortality. Patients with these risk factors should be appropriately monitored to improve outcomes.
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Affiliation(s)
- Derrick O Acheampong
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Philip Paul
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Percy Boateng
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - I Michael Leitman
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
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Soekhai V, de Bekker-Grob EW, Ellis AR, Vass CM. Discrete Choice Experiments in Health Economics: Past, Present and Future. PHARMACOECONOMICS 2019; 37:201-226. [PMID: 30392040 PMCID: PMC6386055 DOI: 10.1007/s40273-018-0734-2] [Citation(s) in RCA: 375] [Impact Index Per Article: 75.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
OBJECTIVES Discrete choice experiments (DCEs) are increasingly advocated as a way to quantify preferences for health. However, increasing support does not necessarily result in increasing quality. Although specific reviews have been conducted in certain contexts, there exists no recent description of the general state of the science of health-related DCEs. The aim of this paper was to update prior reviews (1990-2012), to identify all health-related DCEs and to provide a description of trends, current practice and future challenges. METHODS A systematic literature review was conducted to identify health-related empirical DCEs published between 2013 and 2017. The search strategy and data extraction replicated prior reviews to allow the reporting of trends, although additional extraction fields were incorporated. RESULTS Of the 7877 abstracts generated, 301 studies met the inclusion criteria and underwent data extraction. In general, the total number of DCEs per year continued to increase, with broader areas of application and increased geographic scope. Studies reported using more sophisticated designs (e.g. D-efficient) with associated software (e.g. Ngene). The trend towards using more sophisticated econometric models also continued. However, many studies presented sophisticated methods with insufficient detail. Qualitative research methods continued to be a popular approach for identifying attributes and levels. CONCLUSIONS The use of empirical DCEs in health economics continues to grow. However, inadequate reporting of methodological details inhibits quality assessment. This may reduce decision-makers' confidence in results and their ability to act on the findings. How and when to integrate health-related DCE outcomes into decision-making remains an important area for future research.
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Affiliation(s)
- Vikas Soekhai
- Section of Health Technology Assessment (HTA) and Erasmus Choice Modelling Centre (ECMC), Erasmus School of Health Policy & Management (ESHPM), Erasmus University Rotterdam (EUR), P.O. Box 1738, Rotterdam, 3000 DR The Netherlands
- Department of Public Health, Erasmus MC, University Medical Center, P.O. Box 2040, Rotterdam, 3000 CA The Netherlands
| | - Esther W. de Bekker-Grob
- Section of Health Technology Assessment (HTA) and Erasmus Choice Modelling Centre (ECMC), Erasmus School of Health Policy & Management (ESHPM), Erasmus University Rotterdam (EUR), P.O. Box 1738, Rotterdam, 3000 DR The Netherlands
| | - Alan R. Ellis
- Department of Social Work, North Carolina State University, Raleigh, NC USA
| | - Caroline M. Vass
- Manchester Centre for Health Economics, The University of Manchester, Manchester, UK
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Hu FY, Fang ZB, Leshnower BG, Duwayri Y, Jordan WD, Gillespie TW, Veeraswamy RK. Contemporary evaluation of mortality and stroke risk after thoracic endovascular aortic repair. J Vasc Surg 2017; 66:718-727.e5. [PMID: 28502542 DOI: 10.1016/j.jvs.2017.01.069] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 01/29/2017] [Indexed: 11/26/2022]
Abstract
OBJECTIVE During the past decade, thoracic endovascular aortic repair (TEVAR) has increased as a treatment option for a variety of aortic pathologic processes. Despite this rise in the use of thoracic stent grafts, real-world outcomes from a robust, adjudicated, contemporary data set have yet to be reported. Previous studies have shown periprocedural mortality rates between 1.5% and 9.5% and procedure-related stroke rates of 2.3% to 8.2%. With advances in device engineering and increased experience of physicians, we hypothesized that the rates of these complications would be reduced in a more recent sample set. The purpose of this study was to determine current rates of mortality and stroke after TEVAR, to identify risk factors that contribute to 30-day mortality, and to develop a simple scoring system that allows risk stratification of patients undergoing TEVAR. METHODS We examined the 30-day mortality rate after TEVAR using the 2013 to 2014 American College of Surgeons National Surgical Quality Improvement Program database. Patients undergoing TEVAR for all aortic disease were identified using procedure codes. Bivariate analyses were performed to evaluate the association of preoperative, intraoperative, and postoperative variables with 30-day mortality, followed by multivariable logistic analysis using preoperative variables only, with P < .10 as the criterion for model entry. The predictive logistic model was internally validated by cross-validation. Variables included in the multivariable model were used to develop a risk score. RESULTS There were 826 patients included. The 30-day mortality and stroke rates were 7.63% (n = 63) and 4.5% (n = 37), respectively. In regression analysis, mortality was independently associated with age ≥80 years (odds ratio [OR], 2.32; 95% confidence interval [CI], 1.25-4.31), emergency case (OR, 2.61; 95% CI, 1.39-4.90), American Society of Anesthesiologists classification >3 (OR, 2.89; 95% CI, 1.34-6.24), transfusion >4 units in the 72 hours before surgery (OR, 2.86; 95% CI, 1.30-6.28), preoperative creatinine concentration ≥1.8 mg/dL (OR, 2.07; 95% CI, 1.05-4.08), and preoperative white blood cell count ≥12 × 109/L (OR, 2.65; 95% CI, 1.41-4.96). Incorporating these factors, a 6-point risk score was generated and demonstrated high predictability for overall 30-day mortality. CONCLUSIONS Recent data from a national, retrospective data set demonstrate that high perioperative mortality and stroke rates have persisted during the last decade. The risk score derived from this data set is simple and convenient and serves as a prognostic tool in the preoperative risk stratification of patients being evaluated for TEVAR.
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Affiliation(s)
- Frances Y Hu
- Division of Vascular and Endovascular Therapy, Department of Surgery, Emory University, Atlanta, Ga
| | - Zachary B Fang
- Division of Vascular and Endovascular Therapy, Department of Surgery, Emory University, Atlanta, Ga
| | - Bradley G Leshnower
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University, Atlanta, Ga
| | - Yazan Duwayri
- Division of Vascular and Endovascular Therapy, Department of Surgery, Emory University, Atlanta, Ga
| | - William D Jordan
- Division of Vascular and Endovascular Therapy, Department of Surgery, Emory University, Atlanta, Ga
| | - Theresa W Gillespie
- Department of Surgery and Department of Hematology & Medical Oncology, Emory University, Atlanta, Ga
| | - Ravi K Veeraswamy
- Division of Vascular Surgery, Department of Surgery, the Medical University of South Carolina, Charleston, SC.
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Impact of age and urgency on survival after thoracic endovascular aortic repair. J Vasc Surg 2016; 64:25-32. [PMID: 27103337 DOI: 10.1016/j.jvs.2015.11.054] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Accepted: 11/19/2015] [Indexed: 01/18/2023]
Abstract
OBJECTIVE Elderly patients are often turned down from receiving treatment for descending thoracic aortic diseases (DTADs) because of the uncertain benefits, especially in acute settings. This study investigated the impact of old age and timing of thoracic endovascular aortic repair (TEVAR) on outcomes of DTAD in patients older than 75 years of age. METHODS Patients from a prospective TEVAR database were dichotomized by age (75 and 80 years of age). Older and young patients were compared in three timing scenarios: (1) elective procedures, (2) any emergency (within 15 days from onset), and (3) acute ruptures (any emergency subgroup). Primary outcome was perioperative mortality assessed at 30 and 90 days. RESULTS Between 2003 and 2015, 141 consecutive TEVARs (71.6% men) were performed. Fifty-seven patients (40.4%) were older than 75 years of age; 28 were octogenarians. Eighty-three TEVARs were performed electively and 58 emergently. Among overall emergencies, 42 TEVARs were for acute ruptures. In the elective scenario, the 30-day mortality rate was 5.0% vs 0 (odds ratio [OR], 1.1; 95% confidence interval [CI], 0.98-1.1; P = .23), and 90-day mortality was 7.5% vs 0, for patients older than 75 years of age vs those who were younger than 75, respectively (P = .11). No octogenarian died. In the emergency scenario, 30-day mortality was 41.2% vs 9.8%, for patients older than 75 years of age vs those who were younger than 75, respectively (OR, 6.5; 95% CI, 1.6-26.6; P = .01) with unchanged rates at 90 days. The mortality rate was 50% for octogenarians. In the acute rupture scenario, 30-day mortality was 40% vs 11.1% (OR, 5.3; 95% CI, 1.10-25.99; P = .05) for patients older than 75 years of age vs those younger than 75 years of age and 46% vs 10% (OR, 7.5; 95% CI, 1.47-37.46; P = .016) for octogenarians vs younger patients. Rates remained unchanged at 90 days. Patients older than age 75 survived for a mean of 53.98 ± 7.7 months after TEVAR. CONCLUSIONS In the elderly patient population with DTAD, mortality risks from TEVAR are strongly related to timing and age. When compared to younger patients, those older than 75 years of age have three to five times the risk of mortality after urgent or emergent TEVAR. However, older patients should still be considered for emergent life-saving treatment, given that the majority survives.
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Bosanquet DC, Twine CP, Tang TY, Boyle JR, Bell RE, Bicknell CD, Jenkins MP, Loftus IM, Modarai B, Vallabhaneni SR. Pragmatic Minimum Reporting Standards for Thoracic Endovascular Aortic Repair. J Endovasc Ther 2015; 22:356-67. [DOI: 10.1177/1526602815584925] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- David C. Bosanquet
- South East Wales Regional Vascular Network, Royal Gwent Hospital, Newport, Wales, UK
| | - Christopher P. Twine
- South East Wales Regional Vascular Network, Royal Gwent Hospital, Newport, Wales, UK
| | - Tjun Y. Tang
- Department of General Surgery, Changi General Hospital, Singapore
| | - Jonathan R. Boyle
- Regional Vascular Unit, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
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