Nationwide trends in abdominal aortic aneurysm repair and use of endovascular repair in the emergency setting

German nation-wide in-patient treatment of abdominal aortic aneurysm-trends between 2005 and 2019 and impact of the SARS-CoV-2 pandemic

PURPOSE

Aim of this study was to analyze hospitalizations due to ruptured and non-ruptured abdominal aortic aneurysms (rAAA, nrAAA) in Germany between 2005 and 2021 to determine long-term trends in treatment and the impact of the SARS-CoV-2 pandemic.

MATERIALS AND METHODS

Fully anonymized data were available from the research data center (RDC) of the German Federal Statistical Office (Destatis). All German hospitalizations with the ICD-10 code "I71.3, rAAA" and "I71.4, nrAAA" in 2005 and 2010-2021 were analyzed.

RESULTS

We report data of a total of 202,951 hospitalizations. The number of hospitalizations increased from 2005 to 2019 (14,075 to 16,051, + 14.0%). The rate of open repair (OR) constantly decreased, whereas the rate of endovascular aortic repair (EVAR) increased until 2019. During the pandemic, the number of hospitalizations due to nrAAA dropped from 13,887 (86.5%) in 2019 to 11,278 (85.0%) in 2021. The strongest decrease of hospitalizations for AAA was observed during the first wave of the SARS-CoV-2-pandemic in spring 2020 (-25.5%).

CONCLUSION

Over the past decades, we observed an increasing number of hospitalizations due to AAA accompanied by a shift from OR to EVAR especially for nrAAA. During the lockdown measures due to the SARS-CoV-2-pandemic, a decrease in hospitalizations for nrAAA (but not for rAAA) was shown in 2020 and furthermore in 2021 with no rebound of treatment of nrAAA suggesting an accumulation of untreated AAA with a potentially increased risk of rupture.

The Challenge of Endoleaks in Endovascular Aneurysm Repair (EVAR): A Review of Their Types and Management

An abdominal aortic aneurysm (AAA) is a dilatation of the abdominal aorta above 3 cm or 50% greater than the segment above. It is a dangerous condition accounting for a substantial number of deaths per year and increasing at an alarming rate. Various factors come into play in the development of AAAs, which this study has elaborated on, including smoking and old age, demographics, and comorbid conditions. Endovascular aneurysm repair (EVAR) is a newer treatment modality used for AAAs in which an endograft device is placed into the aorta, thereby creating a bypass tract from the aneurysm and generating flow mimicking that of the natural aorta. It is minimally invasive and associated with less postoperative mortality and reduced hospital stay. However, EVAR is also associated with significant postoperative complications, including endoleaks, which were reviewed in depth. Endoleaks are postprocedural leaks into the aneurysm sac that are usually identified immediately after graft placement and indicate treatment failure. They are of five subtypes, categorized according to their mechanism of development. The most common type is type II endoleaks, and the most dangerous is type I endoleaks. Each subtype has multiple management options with varying rates of success. Prompt identification along with appropriate treatment of endoleaks can lead to better postoperative outcomes and improved quality of life for patients.

Epidemiology of Abdominal Aortic Aneurysm Repair in Brazil from 2008 to 2019 and Comprehensive Review of Nationwide Statistics Across the World

INTRODUCTION

Studying epidemiology of abdominal aortic aneurysms repairs is essential to prevent related deaths. Although outcomes are influenced by socioeconomic factors, there are no nationwide studies on these statistics in low-and-middle income countries. Therefore, we designed this study to evaluate abdominal aortic aneurysms repair rates, trends, costs, and in-hospital mortality in the Brazilian Public Health System, which exclusively insures over 160 million Brazilians.

MATERIAL AND METHODS

Retrospective cross-sectional population-based analysis of publicly available data referring to all abdominal aortic aneurysm repairs performed between 2008 and 2019 in Brazilian public hospitals.

RESULTS

We observed a total of 13,506 abdominal aortic aneurysm repairs, of which 32% were emergency endovascular repairs, 20% emergency open repairs, 32% elective endovascular repairs and 16% elective open repairs. There has been a downward trend in total abdominal aortic aneurysms repairs and an increasing predominance of endovascular repair. Elective and endovascular repairs were significantly associated with lower in-hospital mortality. For ruptured abdominal aortic aneurysms, we observed mortality rates of 13.8% after endovascular repair and 52.1% after open repair. For intact abdominal aortic aneurysms, we observed mortalities of 3.8% after endovascular repair and 18.6% after open repair. Procedure and mortality rates varied significantly among the Brazilian regions.

CONCLUSIONS

We observed a low and decreasing rate of abdominal aortic aneurysm repair. Most repairs were emergency and endovascular and there was an increasing predominance of endovascular repair. Endovascular and elective repairs were associated with lower mortality.

Outcomes of abdominal aortic aneurysm repairs: Endovascular aneurysm vs open surgical repairs

BACKGROUND

Operative mortality after endovascular aneurysm repair (EVAR) has been reported as lower than open surgical repair (OSR) for abdominal aortic aneurysm (AAA) in randomized controlled trials. However, many cohort studies have demonstrated similar mortality rates for both procedures. We compared operative mortality between EVAR and OSR, at our institution.

METHODS

All AAA operations from 2012 to 2017 were reviewed, and baseline characteristics were collected. Outcomes included 30-day mortality, operative data, complications, length of hospital stay (LOS), costs, re-intervention, and survival rates were compared. A multivariable analysis with unbalanced characteristics was performed.

RESULTS

We had a total of 162 patients, 100 having OSR and 62 for EVAR. The EVAR group was older, with higher ASA classification. Thirty-day mortality rate did not significantly differ (0/100 for OSR and 2/62 (3%) for EVAR; p = 0.145), while the EVAR group had less blood loss, shorter operative times, and LOS, but higher re-intervention rates (adjusted hazard ratio 6.4 (95%CI: 1.4, 26.8)). Survival rates did not significantly differ between the groups. EVAR cost approximately 1-million yen more.

CONCLUSIONS

OSR had low 30-day mortality rate in selected low-risk patients whereas EVAR had less blood loss, shorter operative times, LOS and could be done in high-risk patients with low 30-day mortality but with higher re-intervention rate.

National temporal trends and determinants of cost of abdominal aortic aneurysm repair

INTRODUCTION

In recent decades, there has been a shift in the management of aortic abdominal aneurysm from open intervention (open aortic aneurysm repair) to an endovascular approach (endovascular aortic aneurysm repair). This shift has yielded clinical as well as socioeconomic reverberations. In our current study, we aim to analyze these effects brought about by the switch to endovascular treatment and to scrutinize the determinants of cost variations between the two treatment modalities.

METHODS

The National (Nationwide) Inpatient Sample database was queried for clinical data ranging from 2001 to 2013 using International Classification of Disease, 9th Revision (ICD-9) codes for open and endovascular aortic repair. Clinical parameters and financial data related to the two treatment modalities were analyzed. Temporal trends of index hospitalization costs were determined. Multivariate linear regression was used to characterize determinants of cost for endovascular aneurysm repair and open abdominal aortic aneurysm repair.

RESULTS

A total of 128,154 aortic repairs were captured in our analysis, including 62,871 open repairs and 65,283 endovascular repairs. Over the assessed time period, there has been a decrease in the cost of elective endovascular aortic aneurysm repair from $34,975.62 to $31,384.90, a $3,590.72 difference (p < 0.01), while the cost of open aortic repair has increased from $37,427.77 to $43,640.79 by 2013, a $6,212.79 increase (p < 0.01). The cost of open aortic aneurysm repair disproportionately increased at urban teaching hospitals, where by 2013, it costs $50,205.59, compared to $34,676.46 at urban nonteaching hospitals, and $34,696.97 at rural institutions. Urban teaching hospitals were found to perform an increasing proportion of complex open aneurysm repairs, involving concomitant renal and visceral bypass procedures. On multivariate analysis, strong determinants of cost increase for both endovascular aortic aneurysm repair and open aortic aneurysm repair are rupture status, prolonged length of stay, occurrence of complications, and the need for disposition to a nursing facility or another acute care institution.

CONCLUSION

As the vascular community has shifted from an open repair of abdominal aortic aneurysm to an endovascular approach, a number of unforeseen clinical and economic effects were noted. We have characterized these ramifications to help guide further clinical decision and resource allocation.

Frequency of 30-Day Readmission and Its Causes After Endovascular Aneurysm Intervention of Abdominal Aortic Aneurysm (from the Nationwide Readmission Database)

Endovascular aneurysm intervention (EVAI) is one of the most commonly performed vascular interventions for abdominal aortic aneurysm (AAA). Data regarding 30-day readmission rates after EVAI are poorly reported in the literature. We used the United States Nationwide Readmission Database from 2010 to 2014 to identify all patients ≥18 years who were readmitted within 30 days after a hospital discharge for EVAI of the AAA. Incidence, etiologies, predictors of 30-day readmission, and trends of readmission rates were analyzed. In 138,014 patients who survived to discharge after an EVAI procedure for AAA, 14,146 (10.24%) were readmitted within 30 days. Median time to readmission was 11 days. Cardiac causes (16.34%) followed by infections (15.40%) and vascular complications (12.86%) were common etiologies of readmission. Greater patient age, female sex, coexisting co-morbidities such as heart failure, atrial fibrillation, peripheral vascular disease, lung disease, and chronic kidney disease were independent predictors of 30-day readmission. In-hospital complications during an index admission such as major bleeding or vascular complications were also predictive of 30-day readmission. Trend analysis showed a progressive decline in readmission rates from 11.3% in 2010 to 9.6% in 2014 (p_trend <0.0001), 20% lower odds in 2014 compared with 2010 (odds ratio 0.80, 95% confidence interval 0.72 to 0.87, p <0.0001). In this contemporary study of EVAI for AAA, nearly 1 in 10 patients was readmitted within 30 days of discharge after an index admission. Cardiac complications and infections were common causes of readmission within 30 days.

Editor's Choice - Trend-break in Abdominal Aortic Aneurysm Repair With Decreasing Surgical Workload

BACKGROUND

The epidemiology and management of abdominal aortic aneurysms (AAAs) has changed drastically in the past decades, with implementation of nationwide screening programs, introduction of endovascular repair (EVAR), and reduced prevalence of the disease. This report aims to assess recent trends in AAA repair epidemiology in Sweden in this context.

METHODS

Primary AAA repairs registered in the nationwide Swedish Vascular Registry (Swedvasc) 1994-2014 were analyzed regarding patient characteristics, repair incidence, technique, and outcome. Four time periods were compared: 1994-1999, 2000-2004, 2005-2009, and 2010-2014.

RESULT

The incidence of intact AAA repair increased (18.4/100,000 1994-1999, 27.3/100,000 2010-2014, p < .001) predominantly among octogenarians (12.7/100,000 1994-1999, 36.0/100,000 2010-2014, p < .001). The utilization of EVAR increased (58% of all intact AAA repairs 2010-2014), especially among octogenarians (80% 2010-2014). During the last time period, however, the incidence of intact AAA repair stabilized, despite an increasing number of screening-detected AAAs operated on (19% in 2010-2014). Short- and long-term outcome after intact AAA repair continued to improve, most pronounced among octogenarians (30-day mortality 9% 1994-1999, 2% 2010-2014, p < .001). The incidence of ruptured AAA repair steadily decreased (9.2/100,000 1994-1999, 6.9/100,000 2010-2014, p < .001) and the use of EVAR for ruptures increased (30% in 2010-2014). The previously observed improvement of short- and long-term outcome after ruptured AAA repair (30-day mortality 38% 1994-1999, 28% 2010-2014, p < .001) stalled during the last time period. The overall 30-day mortality after ruptured AAA repair was 22% after EVAR versus 31% after open repair in 2010-2014. The corresponding mortality for octogenarians was 28% versus 42%.

CONCLUSIONS

For the first time, a halt in intact AAA repair workload could be identified. This trend-break occurred despite continued increase in treatment of octogenarians and screening-detected aneurysms. Additionally, the ruptured AAA repair incidence continued to decrease. These findings, together with the sustained improvement in survival after AAA repair, may have important impact on planning of vascular surgical services.

Predicting Mortality of Ruptured Abdominal Aortic Aneurysms in the Era of Endovascular Repair

BACKGROUND

Previous risk prediction models of mortality after ruptured abdominal aortic aneurysm (rAAA) repair have been limited by imprecision, complexity, or inclusion of variables not available in the preoperative setting. Most importantly, these prediction models have been derived and validated before the adoption of endovascular aneurysm repair (EVAR) as a treatment for rAAA. We sought to derive and validate a new risk-prediction tool using only easily obtainable preoperative variables in patients with rAAA who are being considered for repair in the endovascular era.

METHODS

We used the Vascular Study Group of New England (VSGNE) database to identify all patients who underwent repair of RAAA (2006-2015). Variables were entered into a multivariable logistic regression model to identify independent predictors of 30-day mortality. Linear regression was then used to develop an equation to predict risk of 30-day mortality.

RESULTS

During the study period, 649 patients underwent repair of rAAA; of these, 247 (38.1%) underwent EVAR and 402 (61.9%) underwent an open repair. The overall mortality associated with rAAA was 30.7% (open, 33.4% and EVAR, 26.2%). On multivariate modeling, the primary determinants of 30-day mortality were advanced age (>76 vs. ≤76 years, odds ratio [OR] = 2.91 and CI: 2.0-4.24), elevated creatinine (>1.5 mg/dL vs. ≤1.5 mg/dL, OR = 1.57 and CI: 1.05-2.34), and lowest systolic blood pressure (SBP) (BP <70 mm Hg vs. ≥70 mm Hg, OR = 2.65 and CI: 1.79-3.92). The logistic regression model had an area under a c-statistic of 0.69. The corresponding linear model used to provide a point estimate of 30-day mortality (%) was % mortality = 14 + 22 * (age >76) + 9 * (creatinine >1.5) + 20 * (bp <70) Using this model, patients can be stratified into different groups, each with a specific estimated risk of 30-day mortality ranging from a low of 14% to a high of 65%.

CONCLUSIONS

In the endovascular era where both open and endovascular treatment are offered for the treatment of rAAA three variables, easily obtained in an emergency setting, accurately predict 30-day mortality for patients operated on for rAAA. This simple risk prediction tool could be used as a point of care decision aid to help the clinician in counseling patients and their families on treatment of those presenting with rAAA.

Trends in Endovascular Aortic Aneurysm Repair Length of Stay over a Decade at a Tertiary Academic Institution

BACKGROUND

Length of stay (LOS) is used as a quality metric to reduce cost and improve value of delivery of care. We sought to analyze trends in endovascular aortic aneurysm repair (EVAR) LOS at a tertiary academic institution over the last decade.

METHODS

A retrospective review of prospectively collected data was performed. Infrarenal EVARs from 2001 to 2013 were divided into 3 groups: group I (2001-2004), EVARs were performed as part of clinical trials; group II (2005-2008), EVARs were referred to a tertiary referral center with the most experience with EVAR; group III (2009-2013), EVARs were referred to academic institutions in the presence of severe patient comorbidities. Trends in LOS and correlation with severity of illness (SOI) as based on All Patient Refined Diagnosis Related Groups and admission and/or disposition status were analyzed. LOS index (LOSI) at our institution was then compared with University HealthSystem Consortium (UHC) Hospitals over the past 3 years.

RESULTS

A total of 1,265 EVARs were performed during this time period: 325 in group I, 547 in group II, and 393 in group III. The median LOS was 4 days (inter quartile range [IQR], 2-6) vs. 3 days (IQR, 2-5) ± 0.28 vs. 4 days (IQR, 3-7), respectively (P < 0.01). Although moderate SOI was fairly constant over time (P = 0.66), major and/or extreme SOI constituted a greater proportion of patients in group I, was reduced in group II, and was again increased in group III, P < 0.01. The complication rate paralleled this pattern (group I, 15.2%; group II, 8.6%; group III, 10.4%; P = 0.02). The percentage of patients discharged to nursing home and/or rehab was 5.7% in group I, 8.2% in group II, 11.5% in group III (P = 0.03). Cases that were performed urgently and/or emergently increased over time: 11.6% in group I, 14.9% in group II, 21.6% in group III (P = 0.01). The risk-adjusted LOSI at our institution was significantly greater (1.25) when compared with UHC hospitals (0.75).

CONCLUSIONS

Our study suggests a relationship between time period of EVAR, SOI, complications, admission status, and LOS. Attention to these trends could be used to decrease LOS in an increasingly complex patient population.

Effects of weekend admission on the outcomes and management of ruptured aortic aneurysms

OBJECTIVE

Ruptured aortic aneurysm is a condition with a high rate of mortality that requires prompt surgical intervention. It has been noted that in some conditions requiring such prompt intervention, in-hospital mortality is increased in patients admitted on the weekends compared with patients admitted on weekdays. We sought to determine if this was indeed the case for both ruptured thoracic aortic aneurysms (TAA) and abdominal aortic aneurysms (AAA) and to elucidate the possible reasons.

METHODS

Using the Nationwide Inpatient Sample, a publicly available database of inpatient care, we analyzed the incidence of mortality among 7200 patients admitted on the weekends compared with weekdays for ruptured aortic aneurysm. Among these patients, 19% had a TAA and 81% had an AAA, and each group was analyzed for differences in mortality during the hospitalization. We adjusted for demographics, comorbid conditions, hospital characteristics, rates of surgical intervention, timing of surgical intervention, and use of additional therapeutic measures.

RESULTS

Patients admitted on the weekend for both ruptured TAA and AAA had a statistically significant increase in mortality compared with those admitted on the weekdays (TAA: odds ratio, 2.55; 95% confidence interval, 1.77-3.68; P = .03; AAA: odds ratio, 1.32; 95% confidence interval, 1.13-1.55; P = .0004). Among those with TAA, a surgical intervention was performed on day of admission in 62.1% of weekday admissions vs 34.9% of weekend admissions (P < .0001). This difference was much smaller among those with an aortic aneurysm; 79.6% had a surgical intervention on day of admission on a weekday vs 77.2% on the weekend (P < .0001).

CONCLUSIONS

Weekend admission for ruptured aortic aneurysm is associated with an increased mortality compared with admission on a weekday, and this is likely due to several factors including a delay in prompt surgical intervention.

Adding an endovascular aortic surgery program to a rural regional medical centre

BACKGROUND

Abdominal aortic aneurysms requiring surgical intervention are generally treated by endovascular means. Such procedures are not always offered in rural hospitals, possibly leaving patients underserved. We reviewed our experience initiating an endoaortic surgery program.

METHODS

A surgeon in a rural centre was credentialed to perform endovascular aortic aneurysm repair through collaboration with a university centre and was proctored locally for the first 5 abdominal aneurysm repairs. Web-based image storage was used to review complex cases as part of an ongoing partnership. Referred patients were screened for multiple aneurysms and underwent long-term monitoring.

RESULTS

In all, 160 patients were evaluated for 176 aortic pathologies. Twenty-five patients (17 men) aged 55-89 years underwent 26 endovascular abdominal (n = 23) or thoracic (n = 3) aortic procedures. Emergent endovascular procedures were not performed. There were no operative deaths, requirements for dialysis or conversions to open repair. Two endoleaks required early reintervention. The median length of stay in hospital for endovascular procedures was 2.5 days. Chronic endoleaks were observed in 7 patients. An additional 8 patients underwent open abdominal aneurysm repair locally and 15 patients were referred to the university program.

CONCLUSION

Creation of an endovascular aortic surgery program in a rural hospital is feasible through collaboration with a high-volume centre. Patient safety is enhanced by obtaining second opinions using web-based image review. Most interventions are for abdominal aortic aneurysms, but planning for a comprehensive aortic clinic is preferable.