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Gormley S, Bernau O, Xu W, Khashram M. Propensity score analysis demonstrates no long term survival benefit from contemporary endovascular aneurysm repair compared to open in Aotearoa New Zealand. ANZ J Surg 2024; 94:819-825. [PMID: 38131414 DOI: 10.1111/ans.18815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 11/20/2023] [Accepted: 11/26/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Current guidelines for AAA management are based on landmark trials comparing EVAR and open aneurysm repair (OAR) conducted more than 20 years ago. Important advancements have been made in peri-operative care but the impact of EVAR and OAR on long-term patient survival has not been well reported using contemporary data. The objective of this study was to compare the short and long-term outcomes of OAR and EVAR in the recent era. METHODS This retrospective observational study included all patients undergoing intact AAA repair in NZ from 1st of January 2011 until 31st of December 2019. Data was collected from national administrative and clinical vascular databases and matched using unique identifiers. Time-to-event survival analyses was conducted using cox proportional hazard models to adjust for confounders and propensity score matching were used. RESULTS Two thousand two hundred and ninety-seven patients had an intact AAA repair with a median (IQR) age of 75 (69-80) years; 494 (21.2%) patients were females and 1206 (53%) underwent EVAR. The 30-day mortality for OAR and EVAR was 4.8% and 1.2%. The median (IQR) follow up was 5.2 (2.3-9.2) years. After propensity matching for co-variates, the study cohort consisted of 835 patients in each matched group. Patients undergoing EVAR had a higher overall mortality (HR 1.48 (95% CI: 1.26-1.74) after adjusting for confounders compared to OAR. CONCLUSION Analysis of survival following EVAR and OAR in the current era demonstrates that patients that underwent EVAR had a lower 30-day mortality. However, in the long-term after adjusting for confounders OAR had a better overall survival.
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Affiliation(s)
- Sinead Gormley
- Department of Vascular & Endovascular Surgery, Waikato Hospital, Hamilton, New Zealand
- Faculty of Medical & Health Sciences, University of Auckland, Auckland, New Zealand
| | - Oliver Bernau
- Faculty of Medical & Health Sciences, University of Auckland, Auckland, New Zealand
| | - William Xu
- Faculty of Medical & Health Sciences, University of Auckland, Auckland, New Zealand
| | - Manar Khashram
- Department of Vascular & Endovascular Surgery, Waikato Hospital, Hamilton, New Zealand
- Faculty of Medical & Health Sciences, University of Auckland, Auckland, New Zealand
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van Ooij P. Editorial for "Dynamic Contrast-Enhanced MRI in Abdominal Aortic Aneurysms as a Potential Marker for Disease Progression". J Magn Reson Imaging 2023; 58:1268-1269. [PMID: 36762910 DOI: 10.1002/jmri.28635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 12/20/2022] [Indexed: 02/11/2023] Open
Affiliation(s)
- Pim van Ooij
- Department of Radiology & Nuclear Medicine, Amsterdam University Medical Center location AMC, Amsterdam, the Netherlands
- Amsterdam Cardiovascular Sciences, Amsterdam University Medical Center, Amsterdam, the Netherlands
- Amsterdam Movement Sciences, Amsterdam University Medical Center, Amsterdam, the Netherlands
- Department of Paediatric Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands
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Lescan M. Infrarenal abdominal aortic aneurysm repair: past, present and future or tempus rerum imperator. EUROPEAN JOURNAL OF CARDIO-THORACIC SURGERY : OFFICIAL JOURNAL OF THE EUROPEAN ASSOCIATION FOR CARDIO-THORACIC SURGERY 2022; 62:6649622. [PMID: 35876844 DOI: 10.1093/ejcts/ezac388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Indexed: 11/13/2022]
Affiliation(s)
- Mario Lescan
- Department of Thoracic and Cardiovascular Surgery, University Medical Centre Tübingen, Tübingen, Germany
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Gomes WJ. The trade-offs in the making of the interventional heart surgeon. J Card Surg 2021; 37:93-95. [PMID: 34662455 DOI: 10.1111/jocs.16087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Accepted: 10/11/2021] [Indexed: 11/30/2022]
Abstract
The current generation of heart surgeons is experiencing growing consternation with the introduction of the so-called disruptive transcatheter procedures, seemingly threatening the stability and even existence of contemporary cardiovascular surgery. We provide a commentary reporting the comparative outcomes of transcatheter therapies and conventional surgery throughout different scenarios and the evolving superiority of the surgical techniques. The upfront conclusion is that surgeons should strive to keep their surgical skills; the downfall of surgery is not anticipated and as revealed, will hold its ground for the foreseeable future.
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Affiliation(s)
- Walter J Gomes
- Cardiovascular Surgery Discipline, Escola Paulista de Medicina and São Paulo Hospital, Federal University of São Paulo, São Paulo, Brazil
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Boyle JR, Mao J, Beck AW, Venermo M, Sedrakyan A, Behrendt CA, Szeberin Z, Eldrup N, Schermerhorn M, Beiles B, Thomson I, Cassar K, Altreuther M, Debus S, Johal AS, Waton S, Scali ST, Cromwell DA, Mani K. Editor's Choice - Variation in Intact Abdominal Aortic Aneurysm Repair Outcomes by Country: Analysis of International Consortium of Vascular Registries 2010 - 2016. Eur J Vasc Endovasc Surg 2021; 62:16-24. [PMID: 34144883 DOI: 10.1016/j.ejvs.2021.03.034] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 03/17/2021] [Accepted: 03/31/2021] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Outcomes for intact abdominal aortic aneurysm (AAA) repair vary over time and by healthcare system, country, and surgeon. The aim of this study was to analyse peri-operative mortality for intact AAA repair in 11 countries over time and compare outcomes by gender, age, and geographical location. METHODS Prospective data on primary repair of intact AAA were collected from 11 countries through the International Consortium of Vascular Registries (ICVR) and analysed for two time periods, 2010 - 2013 and 2014 - 2016. The primary outcome was peri-operative mortality after endovascular aneurysm repair (EVAR) and open surgical repair (OSR). Multivariable logistic regression models were used to adjust for differences in patient characteristics. RESULTS A total of 103 715 patients were included. The percentage of patients undergoing EVAR increased from 63.6% to 71.2% (p < .001) over the study period. This proportion varied by country from 35% in Hungary to 81% in the United States. Overall peri-operative mortality decreased from 2.1% to 1.6 % (p < .001). Mortality also declined significantly over time for both OSR 4.2% to 3.6 % (p = .002) and EVAR 1.0% to 0.7% (p = .002). Mortality was significantly higher for female than male patients (3.0% vs. 1.6% p < .001). The percentage of patients > 80 years old undergoing AAA repair remained constant at 23.6% (p = .91). Peri-operative mortality was higher for patients > 80 years than for those < 80 years old (2.7% vs. 1.6% p < .001). Forty-six per cent (n = 275) of all EVAR deaths occurred in the over 80s. CONCLUSION The proportion of AAA repairs performed using EVAR has increased over time. Peri-operative mortality continues to decline for both OSR and EVAR. Outcomes however were significantly worse for both women and those aged over 80, so efforts should be focused on these patient groups to further reduce elective AAA mortality rates.
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Affiliation(s)
- Jonathan R Boyle
- Cambridge Vascular Unit, Cambridge University Hospitals NHS Trust & Department of Surgery, University of Cambridge, Cambridge, UK.
| | - Jialin Mao
- Healthcare Policy and Research, Weill Cornell Medical College, New York, NY, USA
| | - Adam W Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Maarit Venermo
- Department of Vascular Surgery, Helsinki University Hospital, Helsinki, Finland
| | - Art Sedrakyan
- Healthcare Policy and Research, Weill Cornell Medical College, New York, NY, USA
| | - Christian-Alexander Behrendt
- Department of Vascular Medicine, Working Group GermanVasc, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Zoltan Szeberin
- Department of Vascular Surgery, Semmelweis University, Budapest, Hungary
| | - Nikolaj Eldrup
- Department of Vascular Surgery, Rigshospitalet, Copenhagen University, Copenhagen, Denmark
| | - Marc Schermerhorn
- Division of Vascular Surgery and Endovascular Therapy, Beth Israel Deaconess Medical Centre, Boston, MA, USA
| | - Barry Beiles
- Australasian Vascular Audit, Australasian Society for Vascular Surgery, Melbourne, Australia
| | - Ian Thomson
- Department of Surgery, University of Otago, Dunedin, New Zealand
| | - Kevin Cassar
- Department of Surgery, Faculty of Medicine and Surgery, University of Malta, Malta
| | - Martin Altreuther
- Department of Vascular Surgery, St. Olavs Hospital, Trondheim, Norway
| | - Sebastian Debus
- Department of Vascular Medicine, Working Group GermanVasc, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Amundeep S Johal
- The Clinical Effectiveness Unit, The Royal College of Surgeons of England, 35-43 Lincoln's Inn Fields, London, United Kingdom
| | - Sam Waton
- The Clinical Effectiveness Unit, The Royal College of Surgeons of England, 35-43 Lincoln's Inn Fields, London, United Kingdom
| | - Salvatore T Scali
- University of Florida College of Medicine, Division of Vascular Surgery & Endovascular Therapy, Gainesville, FL, USA
| | - David A Cromwell
- The Clinical Effectiveness Unit, The Royal College of Surgeons of England, 35-43 Lincoln's Inn Fields, London, United Kingdom
| | - Kevin Mani
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
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Editor's Choice - Fenestrated or Branched Endovascular versus Open Repair for Complex Aortic Aneurysms: Meta-Analysis of Time to Event Propensity Score Matched Data. Eur J Vasc Endovasc Surg 2020; 61:228-237. [PMID: 33288434 DOI: 10.1016/j.ejvs.2020.10.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 07/18/2020] [Accepted: 10/07/2020] [Indexed: 11/21/2022]
Abstract
OBJECTIVE The aim of this review was to investigate comparative outcomes of fenestrated or branched endovascular aneurysm repair (F/BEVAR) with open repair for juxta/para/suprarenal or thoraco-abdominal aortic aneurysms. METHODS Electronic bibliographic sources (MEDLINE and Embase) were interrogated using the Healthcare Databases Advanced Search interface. Eligible studies compared F/BEVAR with open repair for complex aortic aneurysms using propensity score or Cox regression modelling/multivariable logistic regression analysis. Pooled estimates of peri-operative outcomes were calculated using the odds ratio (OR) and 95% confidence interval (CI). The result of time to event analysis was reported as summary hazard ratio (HR) and 95% CI. Random effects models and the inverse variance method were applied. The quality of evidence was graded using the system developed by the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) working group. RESULTS Eleven studies published between 2014 and 2019 were selected for inclusion in qualitative and quantitative synthesis reporting a total of at least 7 061 patients. The odds of peri-operative mortality after F/BEVAR were lower, although not significantly, than after open repair (OR 0.56, 95% CI 0.28-1.12), whereas the hazard of overall mortality during follow up was higher following F/BEVAR, but, again, without reaching statistical significance (HR 1.25, 95% CI 0.93-1.67). The hazard of re-intervention was significantly higher after endovascular therapy (HR 2.11, 95% CI 1.39-3.18). The certainty for the body of evidence for peri-operative and overall mortality during follow up was judged to be very low and moderate, respectively, and for re-intervention it was judged to be high. CONCLUSION The evidence is uncertain about the effect of F/BEVAR on peri-operative mortality when compared with open repair. There is probably no difference in overall survival, but F/BEVAR results in an increased re-intervention hazard. There is a need for high level evidence to inform decision making and vascular/aortic service provision.
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Kyriacou H, Mostafa AMHAM, Sumal AS, Hellawell HN, Boyle JR. Abdominal aortic aneurysms part two: Surgical management, postoperative complications and surveillance. J Perioper Pract 2020; 31:319-325. [PMID: 32895001 PMCID: PMC8406374 DOI: 10.1177/1750458920947352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Large, symptomatic and ruptured abdominal aortic aneurysms are usually treated surgically if patients are deemed fit enough. This may be achieved through endovascular or open surgical repair. The type of treatment that a patient receives is dependant on many factors, such as the rupture status of the aneurysm. Each approach is also associated with different risks and postoperative complications. Multiple guidelines exist to inform the surgical management of abdominal aortic aneurysms. This literature review combines these recommendations and explores the evidence upon which they are based. In addition, it highlights the key perioperative considerations that need to be considered in cases of unruptured and ruptured abdominal aortic aneurysms.
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Affiliation(s)
- Harry Kyriacou
- University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Cambridge, UK
| | - Ahmed M H A M Mostafa
- University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Cambridge, UK
| | - Anoop S Sumal
- University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Cambridge, UK
| | - Holly N Hellawell
- University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Cambridge, UK
| | - Jonathan R Boyle
- Cambridge University Hospitals, NHS Foundation Trust, Cambridge Vascular Unit, Cambridge, Cambridgeshire, UK
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