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Nicaise EH, Palmateer G, Schmeusser BN, Futral C, Liu Y, Goyal S, Nabavizadeh R, Kooby DA, Maithel SK, Sweeney JF, Sarmiento JM, Ogan K, Master VA. Differences in preoperative frailty assessment of surgical candidates by sex, age, and race. Surg Open Sci 2024; 19:172-177. [PMID: 38779040 PMCID: PMC11109462 DOI: 10.1016/j.sopen.2024.05.003] [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] [Received: 04/01/2024] [Revised: 04/10/2024] [Accepted: 05/04/2024] [Indexed: 05/25/2024] Open
Abstract
Introduction Surgical decision-making often relies on a surgeon's subjective assessment of a patient's frailty status to undergo surgery. Certain patient demographics can influence subjective judgment when compared to validated objective assessments. In this study, we explore the relationship between subjective and objective frailty assessments according to patient age, sex, and race. Methods Patients were prospectively enrolled in urology, general surgery, and surgical oncology clinics. Using a visual analog scale (0-100), operating surgeons independently rated the patient's frailty status. Objective frailty was classified using the Fried Frailty Criteria ranging from 0 to 5. Multivariable proportional odds models were conducted to examine the potential association of factors with objective frailty, according to surgeon frailty rating. Subgroup analysis according to patient sex, race, and age was also performed. Results Seven male surgeons assessed 203 patients preoperatively with a median age of 65. A majority of patients were male (61 %), white (67 %), and 60 % and 40 % underwent urologic and general surgery/surgical oncology procedures respectively. Increased subjective surgeon rating (OR 1.69; p < 0.001) was significantly associated with the presence of objective frailty. On subgroup analysis, a higher magnitude of such association was observed more in females (OR 1.86; p = 0.0007), non-white (OR 1.84; p = 0.0019), and older (>60, OR 1.75; p = 0.0001) patients, compared to male (OR 1.45; p = 0.0243), non-white (OR 1.48; p = 0.0109) and patients under 60 (OR 1.47; p = 0.0823). Conclusion The surgeon's subjective assessment of frailty demonstrated tendencies to rate older, female, and non-white patients as frail; however, differences in patient sex, age, and race were not statistically significant.
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Affiliation(s)
- Edouard H. Nicaise
- Department of Urology, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Gregory Palmateer
- Department of Urology, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Benjamin N. Schmeusser
- Department of Urology, Emory University School of Medicine, Atlanta, GA, United States of America
- Department of Urology, Indiana University School of Medicine, Indianapolis, IN, United States of America
| | - Cameron Futral
- Department of Urology, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Yuan Liu
- Department of Urology, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Subir Goyal
- Department of Urology, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Reza Nabavizadeh
- Department of Urology, Mayo Clinic, Rochester, MN, United States of America
| | - David A. Kooby
- Department of Surgical Oncology, Emory University School of Medicine, Atlanta, GA, United States of America
- Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Shishir K. Maithel
- Department of Surgical Oncology, Emory University School of Medicine, Atlanta, GA, United States of America
- Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA, United States of America
| | - John F. Sweeney
- Department of General Surgery, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Juan M. Sarmiento
- Department of General Surgery, Emory University School of Medicine, Atlanta, GA, United States of America
- Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Kenneth Ogan
- Department of Urology, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Viraj A. Master
- Department of Urology, Emory University School of Medicine, Atlanta, GA, United States of America
- Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA, United States of America
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Zhang J, Qiu Y, Zhang H, Fan Y. Impact of frailty on adverse outcomes in patients with abdominal aortic aneurysm undergoing surgery: a systematic review and meta-analysis. J Nutr Health Aging 2024; 28:100213. [PMID: 38489993 DOI: 10.1016/j.jnha.2024.100213] [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: 01/11/2024] [Revised: 03/06/2024] [Accepted: 03/07/2024] [Indexed: 03/17/2024]
Abstract
OBJECTIVE To explore the prognostic role of frailty in patients with abdominal aortic aneurysm (AAA) by conducting this systematic review and meta-analysis METHODS: We conducted an extensive literature search on PubMed, Web of Sciences, and Embase databases to identify studies that reported the association of frailty with postoperative complications, reintervention, or all-cause mortality in patients with AAA after surgery. Short-term mortality was defined by a combination of in-hospital and 30-day death. RESULTS Seven cohort studies reporting on 9 articles with 323,788 AAA patients were included. The reported prevalence of frailty in AAA patients ranged between 2.3% and 34.6%. Pooling the results revealed that frailty was significantly associated with a higher risk of short-term all-cause mortality (adjusted risk ratios [RR] 3.20; 95% confidence intervals [CI] 1.95-5.26), long-term all-cause mortality (adjusted RR 2.86; 95% CI 2.57-3.17), and postoperative complications (adjusted RR 2.19; 95% CI 1.50-3.20) compared to non-frail individuals. However, there was no clear association between frailty and reintervention (HR 1.44; 95% CI 0.97-2.16). CONCLUSIONS Frailty independently predicts the short and long-term survival as well as postoperative complications in patients with AAA undergoing surgery. Assessing frail status may potentially enhance surgical decision-making for these patients.
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Affiliation(s)
- Junfang Zhang
- Department of Medical Nutrition, Nanjing Lishui District People's Hospital, Zhongda Hospital Lishui Branch, Southeast University, Nanjing 211200, China
| | - Yue Qiu
- Institute of Molecular Biology & Translational Medicine, The Affiliated People's Hospital, Jiangsu University, Zhenjiang 212002, China
| | - Heng Zhang
- Department of General Surgery, Nanjing Lishui District People's Hospital, Zhongda Hospital Lishui Branch, Southeast University, Nanjing 211200, China.
| | - Yu Fan
- Institute of Molecular Biology & Translational Medicine, The Affiliated People's Hospital, Jiangsu University, Zhenjiang 212002, China.
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Pyun AJ, Ding L, Hong YH, Magee GA, Tan TW, Paige JK, Weaver FA, Han SM. Prospective assessment of dynamic changes in frailty and its impact on early clinical outcomes following physician-modified fenestrated-branched endovascular repair of complex abdominal and thoracoabdominal aortic aneurysms. J Vasc Surg 2024; 79:506-513.e1. [PMID: 37923022 DOI: 10.1016/j.jvs.2023.10.052] [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: 07/22/2023] [Revised: 10/12/2023] [Accepted: 10/25/2023] [Indexed: 11/07/2023]
Abstract
INTRODUCTION Frailty, a predictor of poor outcomes, has been widely studied as a screening tool in surgical decision-making. However, the impact of frailty on the outcomes after fenestrated-branched endovascular aortic repairs (FBEVARs) is less well established. In addition, the changes in frailty during recovery after FBEVAR are unknown. We aim to assess the impact of frailty on outcomes of high-risk patients undergoing physician-modified FBEVARs for complex abdominal and thoracoabdominal aortic aneurysms, as well as the changes in frailty during follow-up. METHODS Consecutive patients enrolled in a single-center prospective Physician-Sponsored Investigational Device Exemption protocol (FDA# G200159) were evaluated. In addition to the baseline characteristics, frailty was assessed using the Hopkins Frailty Score (HFS) and frailty index (FI) measured by the Frailty Meter. Sarcopenia was measured by L3 total psoas muscle area (PMA). These measurements were repeated during follow-up. The follow-up HFS and FI were compared with baseline scores using the Wilcoxon signed-rank test, whereas follow-up PMA measurements were compared with the baseline using the paired t test. The association between baseline frailty and morbidity was evaluated by the Wilcoxon rank-sum test. RESULTS Seventy patients were analyzed in a prospective Physician-Sponsored Investigational Device Exemption study from February 9, 2021, to June 2, 2023. At baseline, HFS identified 54% of patients as not frail, 43% as intermediately frail, and 3% as frail. Technical success of FBEVAR was 94% with one in-hospital mortality. Early major adverse events were seen in 10 (14.3%) patients. No difference in baseline FI was seen between patients with early morbidity and those without. Patients who were not frail per HFS were less likely to experience early morbidity (P = .033), and there was a significantly lower baseline PMA in patients who experienced early morbidity (P = .016). At 1 month, patients experienced a significant increase in HFS and HFS category (P = .001 and P = .01) and a significant decrease in sarcopenia (mean PMA: -96 mm2, P = .005). At 6 months, HFS and HFS category as well as PMA returned toward baseline (P = .42, P = .38, and mean PMA: +4 mm2, P = .6). CONCLUSIONS Preoperative frailty and sarcopenia were associated with early morbidity after physician-modified FBEVAR. During follow-up, patients became more frail and sarcopenic by 1 month. Recovery from this initial decline was seen by 6 months, suggesting that frailty and sarcopenia are reversible processes rather than a unidirectional phenomenon of continued decline.
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Affiliation(s)
- Alyssa J Pyun
- Comprehensive Aortic Center, Division of Vascular and Endovascular Therapy, Keck Medical Center of University of Southern California, Los Angeles, CA
| | - Li Ding
- Comprehensive Aortic Center, Division of Vascular and Endovascular Therapy, Keck Medical Center of University of Southern California, Los Angeles, CA
| | - Yong H Hong
- Comprehensive Aortic Center, Division of Vascular and Endovascular Therapy, Keck Medical Center of University of Southern California, Los Angeles, CA
| | - Gregory A Magee
- Comprehensive Aortic Center, Division of Vascular and Endovascular Therapy, Keck Medical Center of University of Southern California, Los Angeles, CA
| | - Tze-Woei Tan
- Comprehensive Aortic Center, Division of Vascular and Endovascular Therapy, Keck Medical Center of University of Southern California, Los Angeles, CA
| | - Jacquelyn K Paige
- Comprehensive Aortic Center, Division of Vascular and Endovascular Therapy, Keck Medical Center of University of Southern California, Los Angeles, CA
| | - Fred A Weaver
- Comprehensive Aortic Center, Division of Vascular and Endovascular Therapy, Keck Medical Center of University of Southern California, Los Angeles, CA
| | - Sukgu M Han
- Comprehensive Aortic Center, Division of Vascular and Endovascular Therapy, Keck Medical Center of University of Southern California, Los Angeles, CA.
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Pumares-García L, Paredes-Mariñas E, Calsina-Juscafresa L, Subirana-Cachinero I, Miralles-Hernández M, Clarà-Velasco A. Association of polypharmacy scores with the long-term survival of patients with intact aortoiliac aneurysms and indication for repair. J Vasc Surg 2024; 79:540-546.e2. [PMID: 37923020 DOI: 10.1016/j.jvs.2023.10.051] [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: 07/30/2023] [Revised: 10/20/2023] [Accepted: 10/25/2023] [Indexed: 11/07/2023]
Abstract
OBJECTIVE/BACKGROUND Our study analyzed the relationship between two polypharmacy scores (addition of chronic prescribed drugs [ACPDs] and Rx-Risk Comorbidity Index) and survival in patients with an intact abdominal aortic and/or common iliac aneurysm (AAA). METHODS Consecutive retrospective, single-center cohort of patients attended for an intact AAA with indication for repair from 2008 to 2021. Demographic data, Charlson Comorbidity Index, AAA treatment, ACPD, and Rx-Risk polypharmacy scores were recorded at baseline. Main outcomes were the 5-year and long-term survival rates. The statistical analysis included Cox regression, area under the curve, and continuous net reclassification index. RESULTS A total of 424 patients with AAA were evaluated (median age: 76 years; 92.2% male, median Charlson index 2), of whom 314 (74.1%) underwent intervention (80% endovascular and 20% open) and 110 (25.9%) did not. During follow-up (mean 4.6 years), 245 patients (57.8%) died, with 1-month, 1-year, and 5-year survival rates of 98.1%, 86.3%, and 52.7%, respectively. ACPD and Rx-Risk indices (median [interquartile range]: 6 [4-9] and 3 [0-5], respectively) were significantly and linearly associated (P < .001) with survival, with the best cutoff points at 5 and 0, respectively. An ACPD >5 (patients with >5 chronically prescribed drugs at baseline) and an Rx-Risk >0 were associated with a 45.2% (P = .038) and 102% (P = .002) increase in 5-year mortality, respectively, after adjustment for age, sex, Charlson index, and type of AAA treatment. Both polypharmacy indices improved significantly the discriminative power of the Charlson Comorbidity Index in predicting survival. CONCLUSIONS Both ACPD and Rx-Risk polypharmacy scores are independently related to survival among patients with an intact AAA and indication for repair. Their behavior is similar, so the simple ACPD >5 appears to be sufficient to identify patients with lower survival rates.
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Affiliation(s)
| | - Ezequiel Paredes-Mariñas
- Department of Vascular and Endovascular Surgery, Hospital del Mar, Barcelona, Spain; Department of Surgery, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Laura Calsina-Juscafresa
- Department of Vascular and Endovascular Surgery, Hospital del Mar, Barcelona, Spain; Department of Medicine and Health Sciences, Universitat Pompeu Fabra, Barcelona, Spain
| | - Isaac Subirana-Cachinero
- Hospital del Mar Research Institute, Barcelona, Spain; CIBER Cardiovascular, IMIM-Parc de Salut Mar, Barcelona, Spain
| | | | - Albert Clarà-Velasco
- Department of Vascular and Endovascular Surgery, Hospital del Mar, Barcelona, Spain; Department of Medicine and Health Sciences, Universitat Pompeu Fabra, Barcelona, Spain; CIBER Cardiovascular, IMIM-Parc de Salut Mar, Barcelona, Spain.
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Welsh SA, Pearson RC, Hussey K, Brittenden J, Orr DJ, Quinn T. A systematic review of frailty assessment tools used in vascular surgery research. J Vasc Surg 2023; 78:1567-1579.e14. [PMID: 37343731 DOI: 10.1016/j.jvs.2023.06.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 06/07/2023] [Accepted: 06/10/2023] [Indexed: 06/23/2023]
Abstract
OBJECTIVE Frailty is common in vascular patients and is recognized for its prognostic value. In the absence of consensus, a multitude of frailty assessment tools exist. This systematic review aimed to quantify the variety in these tools and describe their content and application to inform future research and clinical practice. METHODS Multiple cross-disciplinary electronic literature databases were searched from inception to August 2022. Studies describing frailty assessment in a vascular surgical population were eligible. Data extraction to a validated template included patient demographics, tool content, and analysis methods. A secondary systematic search for papers describing the psychometric properties of commonly used frailty tools was then performed. RESULTS Screening 5358 records identified 111 eligible studies, with an aggregate population of 5,418,236 patients. Forty-three differing frailty assessment tools were identified. One-third of these failed to assess frailty as a multidomain deficit and there was a reliance on assessing function and presence of comorbidity. Substantial methodological variability in data analysis and lack of methodological description was also identified. Published psychometric assessment was available for only 4 of the 10 most commonly used frailty tools. The Clinical Frailty Scale was the most studied and demonstrates good psychometric properties within a surgical population. CONCLUSIONS Substantial heterogeneity in frailty assessment is demonstrated, precluding meaningful comparisons of services and data pooling. A uniform approach to assessment is required to guide future frailty research. Based on the literature, we make the following recommendations: frailty should be considered a continuous construct and the reporting of frailty tools' application needs standardized. In the absence of consensus, the Clinical Frailty Scale is a validated tool with good psychometric properties that demonstrates usefulness in vascular surgery.
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Affiliation(s)
- Silje A Welsh
- College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, Scotland; Department of Vascular Surgery, Queen Elizabeth University Hospital, Glasgow, Scotland.
| | - Rebecca C Pearson
- Department of Medicine for the Elderly, Glasgow Royal Infirmary, Glasgow, Scotland
| | - Keith Hussey
- Department of Vascular Surgery, Queen Elizabeth University Hospital, Glasgow, Scotland
| | - Julie Brittenden
- College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, Scotland; Department of Vascular Surgery, Queen Elizabeth University Hospital, Glasgow, Scotland
| | - Douglas J Orr
- College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, Scotland; Department of Vascular Surgery, Queen Elizabeth University Hospital, Glasgow, Scotland
| | - Terry Quinn
- College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, Scotland
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Ramkumar N, Suckow BD, Columbo JA, Arya S, Sedrakyan A, Mackenzie TA, Brown JR, Goodney PP. Sex differences in outcomes among adults undergoing abdominal aortic aneurysm repair. J Vasc Surg 2023; 78:1212-1220.e5. [PMID: 37442215 DOI: 10.1016/j.jvs.2023.06.105] [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: 10/12/2022] [Revised: 06/28/2023] [Accepted: 06/30/2023] [Indexed: 07/15/2023]
Abstract
OBJECTIVE Although the differences in short-term outcomes between male and female patients in abdominal aortic aneurysm (AAA) repair have been well studied, it remains unclear if these sex disparities extend to other long-term adverse outcomes after AAA repair, such as reintervention and late rupture. METHODS We performed a retrospective cohort study of 13,007 patients who underwent either endovascular (EVAR) or open AAA repair (OAR) between 2003 and 2015 using data from the Vascular Quality Initiative registries. Eligible patients were linked to fee-for-service Medicare claims to identify late outcomes of rupture and aneurysm-specific reintervention. RESULTS The mean age of our cohort was 76 ± 6.7 years, 22% were female, 94% were White, and 77% underwent EVAR. The 10-year rupture incidence was slightly higher for women at 4.8 per 1000 person-years, vs 3.9 for men, but this difference was not statistically significant after risk adjustment (hazard ratio [HR] = 1.13, 95% confidence interval [CI]: 0.74-1.73). Likewise, we found no sex difference in reintervention rates (5.1 vs 4.8 in women per 1000 person-years) even after risk adjustment (HR = 0.95, 95% CI: 0.83-1.09). Regression models suggest effect modification by repair type for reintervention, where women who underwent index EVAR had a higher risk of reintervention than men (HR = 1.08, 95% CI: 0.93-1.26), whereas women who underwent OAR were at a lower risk of reintervention than men (HR = 0.79, 95% CI: 0.58-1.08); however, neither effect reached statistical significance within each subgroup. In addition, we found that the risk of reintervention for women vs men varied by clinical presentation, where women were less likely to undergo reintervention after an elective or symptomatic AAA repair but were more likely to undergo reintervention after a repair for AAA rupture (HR = 1.70, 95% CI: 1.05-2.75). CONCLUSIONS Male and female patients who underwent AAA repair had similar rates of reintervention and late aneurysm rupture in the 10 years after their procedure. However, our findings suggest that repair type and clinical presentation may affect the role of sex in clinical outcomes and warrant further exploration in these subgroups.
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Affiliation(s)
| | - Bjoern D Suckow
- Section of Vascular Surgery, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Jesse A Columbo
- Geisel School of Medicine, Hanover, NH; Section of Vascular Surgery, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Shipra Arya
- Department of Surgery, Stanford University Medical Center, Stanford, CA
| | | | - Todd A Mackenzie
- Geisel School of Medicine, Hanover, NH; Department of Biomedical Data Science, Geisel School of Medicine, Hanover, NH
| | - Jeremiah R Brown
- Department of Biomedical Data Science, Geisel School of Medicine, Hanover, NH; Department of Epidemiology, Geisel School of Medicine, Hanover, NH
| | - Philip P Goodney
- Geisel School of Medicine, Hanover, NH; Section of Vascular Surgery, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
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D'Oria M, Trimarchi S, Lomazzi C, Upchurch GR, Suominen V, Bissacco D, Taglialavoro J, Lepidi S. Incidence, predictors, and prognostic impact of in-hospital serious adverse events in patients ≥75 years of age undergoing elective endovascular aneurysm repair. Surgery 2023; 173:1093-1101. [PMID: 36526489 DOI: 10.1016/j.surg.2022.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Revised: 10/26/2022] [Accepted: 11/13/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND This study sought to identify the factors associated with the occurrence of in-hospital serious adverse events after elective endovascular aortic repair (EVAR) in older patients within the Global Registry for Endovascular Aortic Treatment. METHODS Consecutive patients ages ≥75 years who received GORE EXCLUDER AAA Endoprosthesis (W.L. Gore & Associates, Inc, Flagstaff, AZ) for elective EVAR. Based on the age at index elective EVAR, patients were categorized into 3 groups for subsequent analyses: those ages 75 to 79, 80 to 84, and ≥85 years. The primary end points for this study were the incidence of serious adverse events and all-cause mortality. In-hospital complications were defined according to the International Organization for Standardization 14155 standard (https://www.iso.org/standard/71690.html) and considered serious adverse events if they led to any of the following: (1) a life-threatening illness or injury, (2) a permanent impairment of a body structure or a body function, (3) in-patient or prolonged hospitalization, or (4) medical or surgical intervention to prevent life-threatening illness or injury or permanent impairment to a body structure or a body function. RESULTS Overall, 1,333 older patients (ages 75-79: n = 601; 80-84: n = 474; and ≥85: n = 258) underwent elective EVAR in the Global Registry for Endovascular Aortic Treatment data set and were included in the present analysis. In total, 12 patients (0.9%) died perioperatively, and 103 patients (7.7%) experienced ≥1 in-hospital serious adverse event, with 18 patients (1.3%) experiencing >1 in-hospital complications. No significant differences were seen between the age groups in the rates of in-hospital serious adverse events (7.3% vs 8.2% vs 7.8%; P = .86). In logistic regression analysis, a history of chronic obstructive pulmonary disease (odds ratio = 2.014; 95% confidence interval, 1.215-3.340; P = .006) and prior requirement for dialysis (odds ratio = 4.655; 95% confidence interval, 1.087-19.928; P = .038) resulted as predictors for occurrence of in-hospital serious adverse events. In the whole cohort, the 5-year survival was 63% for patients who did not experience any in-hospital serious adverse events compared with 51% for those who experienced any complications (P = .003). Using multivariable Cox proportional hazards models, it was found that the occurrence of in-hospital serious adverse events (hazard ratio = 6.2; 95% confidence interval, 1.8-21.317; P = .003) and being underweight (hazard ratio = 7.0; 95% confidence interval, 1.371-35.783; P = .019) were the only independent predictors of death in ≤30 days from the initial intervention. Although age did not independently affect the risk for all-cause mortality in ≤180 days after the initial intervention, increasing age was associated with a higher risk for long-term death (ie, ≥181 days from index elective EVAR) in the multivariable analysis (ages 75-79: hazard ratio = 0.379; 95% confidence interval, 0.281-0.512; P < .001; and 80-84: hazard ratio = 0.562; 95% confidence interval, 0.419-0.754; P < .001). CONCLUSION After elective EVAR in older patients (ie, ≥75 years), the occurrence of in-hospital serious adverse events appears to increase the risk of death, particularly in ≤180 days after the initial elective EVAR intervention, and might be related to patient baseline characteristics, including history of pulmonary and renal disease.
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Affiliation(s)
- Mario D'Oria
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste, Italy.
| | - Santi Trimarchi
- Division of Vascular and Endovascular Surgery, IRCCS Ca'Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Chiara Lomazzi
- Division of Vascular and Endovascular Surgery, IRCCS Ca'Granda Ospedale Maggiore Policlinico, Milano, Italy
| | | | - Velipekka Suominen
- Centre for Vascular Surgery and Interventional Radiology, Tampere University Hospital, and Tampere University, Faculty of Medicine and Life Sciences, Tampere, Finland
| | - Daniele Bissacco
- Division of Vascular and Endovascular Surgery, IRCCS Ca'Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Jacopo Taglialavoro
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste, Italy
| | - Sandro Lepidi
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste, Italy
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Balasundaram N, Chandra I, Sunilkumar VT, Kanake S, Bath J, Vogel TR. Frailty Index (mFI-5) Predicts Resource Utilization after Nonruptured Endovascular Aneurysm Repair. J Surg Res 2023; 283:507-513. [PMID: 36436287 DOI: 10.1016/j.jss.2022.10.045] [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: 03/08/2022] [Revised: 07/14/2022] [Accepted: 10/16/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION The 5- factor frailty index (mFI-5) has reliably predicted outcomes after vascular surgeries. The purpose of this study was to determine the performance of this index in aortic endovascular surgery ( endovascular aneurysm repair [EVAR]) MATERIALS AND METHODS: The American College of Surgeons' National Surgical Quality Improvement Program Database (NSQIP) was retrospectively analyzed for patients undergoing nonruptured EVAR between 2015 and 2019. Outcomes were assessed using bivariate analysis (Mann Whitney U test, chi-squared test, and t-test) and multivariate logistic regression analysis. RESULTS 10,450 patients were identified with a mean age of 73.59 (SD 8.93) y. 8222 (78.7%) were performed for large diameter with the remaining indications including dissection, symptomatic, and embolization/thrombosis. 30-d mortality was 1.3%. Univariate analysis showed that mFI-5≥0.6 was associated with higher rates of prolonged hospital stay (18.8% versus 5.7%, P < 0.001, reference mFI-5 = 0), readmission (12.3% versus 5.9%, P < 0.001), mortality (3.6 % versus 1.2%, P = 0.01), intensive care unit (ICU) length of stay more than 3 d (7.2% versus 2.7%, P < 0.001). Female gender higher age, indication for surgery, and mFI-5 were all associated with increased mortality. Multivariate logistic regression showed that mFI-5 remained as a significant predictor with mFI-5≥0.6 predicting a close to 3 times higher odds for 30-d mortality (odds ratio OR 2.83, P = 0.003), ICU length of stay >3 d (OR 2.48, P < 0.001), >7 d hospital stay (OR 3.94, P < 0.001), readmission (OR 2.16, P < 0.001), and pneumonia (OR 4.2, P < 0.001) CONCLUSIONS: The modified frailty index (mFI-5) is a good predictor for postoperative complications and hospital resource utilization after nonruptured EVAR.
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Affiliation(s)
- Naveen Balasundaram
- Division of Vascular Surgery, Department of Surgery, University of Missouri, Columbia, Missouri 65212.
| | - Isaiah Chandra
- School of Medicine, University of Missouri, Columbia, Missouri 65212
| | | | - Shubham Kanake
- School of Medicine, University of Missouri, Columbia, Missouri 65212
| | - Jonathan Bath
- Division of Vascular Surgery, Department of Surgery, University of Missouri, Columbia, Missouri 65212
| | - Todd R Vogel
- Division of Vascular Surgery, Department of Surgery, University of Missouri, Columbia, Missouri 65212
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Characteristics Associated With Failure to Rescue After Open Abdominal Aortic Aneurysm Repair. J Surg Res 2023; 283:683-689. [PMID: 36459861 DOI: 10.1016/j.jss.2022.11.018] [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: 02/28/2022] [Revised: 10/31/2022] [Accepted: 11/08/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Failure to Rescue (FTR), defined as mortality following a complication of care, is an important indicator of hospital care quality. Understanding risk factors associated with FTR in the elective Abdominal Aortic Aneurysm (AAA) population may help surgeons prevent operative mortality. METHODS Elective open AAA repairs (2008-2018) were identified from Cerner's HealthFacts database using ICD-9 and ICD-10 diagnosis and procedure codes. Patient, hospital, and encounter characteristics were analyzed. Multivariate logistic regression models determined the relative contribution of patient and encounter characteristics leading to FTR. RESULTS For 1761 patients who underwent open repair for nonruptured AAA, overall mortality was 6.1%. Of patients with one or more complications (40%), mortality was 9.6%, increasing to 21.5% for patients with ≥4 major complications. Complications of care most associated with death were myocardial infarction (MI), gastrointestinal (GI) bleeding, and pulmonary failure. After multivariable adjustment, FTR was associated with advanced age (odds ratio [OR] 1.19 for 5 y, 95% confidence interval [CI] 1.06-1.34); female sex (OR 1.74, 95% CI 1.12-2.70); congestive heart failure (OR 1.65, 95% CI 1.00-2.73); peptic ulcer disease (OR 3.99, 95% CI 1.18-13.5); diabetes (OR 4.90, 95% CI 1.90-12.6), and the number of complications of care. CONCLUSIONS Complications of care were common following open elective AAA repair. The complications with the highest mortality included MI, GI bleeding, and respiratory failure. FTR was associated with female sex, comorbidities, and increasing numbers of complications of care. Often, the lowest occurring complications had the highest FTR. Adopting gender-specific assessment tools, a protocol-driven approach for perioperative GI prophylaxis, and preoperative MI risk mitigation may lead to reduced FTR.
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Ribieras AJ, Kang N, Shao T, Kenel-Pierre S, Tabbara M, Rey J, Velazquez OC, Bornak A. Effect of Body Mass Index on Early Outcomes of Endovascular Abdominal Aortic Aneurysm Repair. Ann Vasc Surg 2023:S0890-5096(23)00104-8. [PMID: 36812980 DOI: 10.1016/j.avsg.2023.01.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Revised: 01/28/2023] [Accepted: 01/29/2023] [Indexed: 02/22/2023]
Abstract
BACKGROUND This study compares the presentation, management, and outcomes of patients undergoing endovascular abdominal aortic aneurysm repair (EVAR), based on their weight status as defined by their body mass index (BMI). METHODS Patients with primary EVAR for ruptured and intact abdominal aortic aneurysm (AAA) were identified in the National Surgical Quality Improvement Program database (2016-2019). Patients were categorized by weight status (underweight: BMI < 18.5 kg/m2, normal weight: 18.5-24.9 kg/m2, overweight: 25-29.9 kg/m2, Obese I: 30-34.9 kg/m2, Obese II: 35-39.9 kg/m2, Obese III: > 40 kg/m2). Preoperative characteristics and 30-day outcomes were compared. RESULTS Of 3,941 patients, 4.8% were underweight, 24.1% normal weight, 37.6% overweight, and 22.5% with Obese I, 7.8% Obese II, and 3.3% Obese III status. Underweight patients presented with larger (6.0 [5.4-7.2] cm) and more frequently ruptured (25.0%) aneurysms than normal weight patients (5.5 [5.1-6.2] cm and 4.3%, P < 0.001 for both). Pooled 30-day mortality was worse for underweight (8.5%) compared to all other weight status (1.1-3.0%, P < 0.001), but risk-adjusted analysis demonstrated that aneurysm rupture (odds ratio [OR] 15.9, 95% confidence interval [CI] 8.98-28.0) and not underweight status (OR 1.75, 95% CI 0.73-4.18) accounted for increased mortality in this population. Obese III status was associated with prolonged operative time and respiratory complications after ruptured AAA, but not 30-day mortality (OR 0.82, 95% CI 0.25-2.62). CONCLUSIONS Patients at either extreme of the BMI range had the worst outcomes after EVAR. Underweight patients represented only 4.8% of all EVARs, but 21% of mortalities, largely attributed to higher incidence of ruptured AAA at presentation. Severe obesity, on the other hand, was associated with prolonged operative time and respiratory complications after EVAR for ruptured AAA. BMI, as an independent factor, was however not predictive of mortality for EVAR.
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Affiliation(s)
- Antoine J Ribieras
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Naixin Kang
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Tony Shao
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Stefan Kenel-Pierre
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Marwan Tabbara
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Jorge Rey
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Omaida C Velazquez
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Arash Bornak
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL.
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Cardiel-Pérez A, Paredes-Mariñas E, Nieto-Fernández L, Abadal-Jou M, Mellado-Joan M, Clarà-Velasco A. Comparative performance of three comorbidity scores in predicting survival after the elective repair of abdominal aortic aneurysms. INT ANGIOL 2023; 42:73-79. [PMID: 36744425 DOI: 10.23736/s0392-9590.22.04974-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND We aimed to study the discriminative power of 3 comorbidity scores for predicting 5-year survival after the elective repair of aorto-iliac aneurysms (AAA). METHODS 444 patients with AAA undergoing elective repair (33% open and 67% endovascular) between 2000 and 2020 were reviewed. The Charlson Comorbidity Index (CCI) and subsequent adjustments by Schneeweiss, Quan and Armitage, the Modified Frailty Index (MFI) and the American Society of Anesthesiologists Score (ASA) were calculated from preoperative data. Their association with 5-year survival was analyzed using Cox regression models and their discriminative power and its changes with C statistics and Net Reclassification Index (NRI). RESULTS All comorbidity scores were associated with survival after adjusting by age, sex and type of surgical repair: original CCI HR=1.24, P<0.001; Schneeweiss CCI HR=1.23, P<0.001; Quan CCI HR=1.27, P<0.001, Armitage CCI HR=1.46, P<0.001, MFI HR=1.39, P<0.001 and ASA HR=1.68 (P=0.04) and 2.86 (P=0.01) for classes III and IV, respectively. Associated C statistics were of 0.64, 0.65, 0.65, 0.64, 0.61 and 0.59, respectively. Compared with the original CCI, models based on Schneeweiss CCI and Armitage CCI provided minor improvements in NRI (0.32 and 0.23), and the model based on ASA showed lower C statistics (P=0.014) and NRI (-0.30). CONCLUSIONS Established comorbidity scores, such as CCI, MFI or ASA, are all associated with 5-year survival after the elective repair of AAAs, being ASA the worst of them. However, their predictive power is in no case sufficient to identify, by themselves, those patients who may not be eligible for intervention on the basis of life expectancy.
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Affiliation(s)
- Ada Cardiel-Pérez
- Department of Vascular and Endovascular Surgery, Hospital del Mar, Barcelona, Spain
| | - Ezequiel Paredes-Mariñas
- Department of Vascular and Endovascular Surgery, Hospital del Mar, Barcelona, Spain - .,Department of Surgery, Universitat Autonoma de Barcelona, Barcelona, Spain
| | | | - Mar Abadal-Jou
- Department of Vascular and Endovascular Surgery, Hospital del Mar, Barcelona, Spain
| | | | - Albert Clarà-Velasco
- Department of Vascular and Endovascular Surgery, Hospital del Mar, Barcelona, Spain.,CIBER Cardiovascular, Institut Hospital del Mar d'Investigacions Mèdiques, Hospital del Mar, Barcelona, Spain.,Department of Medicine and Surgery, Hospital del Mar, Universitat Pompeu Fabra, Barcelona, Spain
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12
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Weaver ML, Sorber RA, Holscher CM, Cox ML, Henry BV, Brooke BS, Cooper MA. The measurable impact of a diversity, equity, and inclusion editor on diversifying content, authorship, and peer review participation in the Journal of Vascular Surgery. J Vasc Surg 2023; 77:330-337. [PMID: 36368645 DOI: 10.1016/j.jvs.2022.10.052] [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: 06/28/2022] [Revised: 10/09/2022] [Accepted: 10/31/2022] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Women and minorities remain under-represented in academic vascular surgery. This under-representation persists in the editorial peer review process which may contribute to publication bias. In 2020, the Journal of Vascular Surgery (JVS) addressed this by diversifying the editorial board and creating a new Editor of Diversity, Equity, and Inclusion (DEI). The impact of a DEI editor on modifying the output of JVS has not yet been examined. We sought to determine the measurable impact of a DEI editor on diversifying perspectives represented in the journal, and on contributing to changes in the presence of DEI subject matter across published journal content. METHODS The authorship and content of published primary research articles, editorials, and special articles in JVS were examined from November 2019 through July 2022. Publications were examined for the year prior to initiation of the DEI Editor (pre), the year following (post), and from September 2021 to July 2022, accounting for the average 47-week time period from submission to publication in JVS (lag). Presence of DEI topics and women authorship were compared using χ2 tests. RESULTS During the period examined, the number of editorials, guidelines, and other special articles dedicated to DEI topics in the vascular surgery workforce or patient population increased from 0 in the year prior to 4 (16.7%) in the 11-month lag period. The number of editorials, guidelines, and other special articles with women as first or senior authors nearly doubled (24% pre, 44.4% lag; P = .31). Invited commentaries and discussions were increasingly written by women as the study period progressed (18.7% pre, 25.9% post, 42.6% lag; P = .007). The number of primary research articles dedicated to DEI topics increased (5.6% pre, 3.3% post, 8.1% lag; P = .007). Primary research articles written on DEI topics were more likely to have women first or senior authors than non-DEI specific primary research articles (68.0% of all DEI vs 37.5% of a random sampling of non-DEI primary research articles; P < .001). The proportion of distinguished peer reviewers increased (from 2.8% in 2020 to 21.9% in 2021; P < .001). CONCLUSIONS The addition of a DEI editor to JVS significantly impacted the diversification of topics, authorship of editorials, special articles, and invited commentaries, as well as peer review participation. Ongoing efforts are needed to diversify subject matter and perspective in the vascular surgery literature and decrease publication bias.
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Affiliation(s)
- M Libby Weaver
- Division of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, VA.
| | - Rebecca A Sorber
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD
| | - Courtenay M Holscher
- Division of Vascular Surgery and Endovascular Therapy, The Johns Hopkins Hospital, Baltimore, MD
| | - Morgan L Cox
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL
| | - Brandon V Henry
- Division of Vascular Surgery and Endovascular Surgery, Morehouse School of Medicine, Atlanta, GA
| | - Benjamin S Brooke
- Division of Vascular Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT
| | - Michol A Cooper
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL
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Oberhuber A, Raddatz A, Betge S, Ploenes C, Ito W, Janosi RA, Ott C, Langheim E, Czerny M, Puls R, Maßmann A, Zeyer K, Schelzig H. Interdisciplinary German clinical practice guidelines on the management of type B aortic dissection. GEFASSCHIRURGIE 2023; 28:1-28. [PMCID: PMC10123596 DOI: 10.1007/s00772-023-00995-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/14/2023] [Indexed: 08/13/2023]
Affiliation(s)
- A. Oberhuber
- German Society of Vascular Surgery and Vascular Medicine (DGG); Department of Vascular and Endovascular Surgery, University Hospital of Münster, Münster, Germany
| | - A. Raddatz
- German Society of Anaesthesiology and Intensive Care Medicine (DGAI); Department of Anaesthesiology, Critical Care and Pain Medicine, Saarland University Hospital, Homburg, Germany
| | - S. Betge
- German Society of Angiology and Vascular Medicine (DGG); Department of Internal Medicine and Angiology, Helios Hospital Salzgitter, Salzgitter, Germany
| | - C. Ploenes
- German Society of Geriatrics (DGG); Department of Angiology, Schön Klinik Düsseldorf, Düsseldorf, Germany
| | - W. Ito
- German Society of Internal Medicine (GSIM) (DGIM); cardiovascular center Oberallgäu Kempten, Hospital Kempten, Kempten, Germany
| | - R. A. Janosi
- German Cardiac Society (DGK); Department of Cardiology and Angiology, University Hospital Essen, Essen, Germany
| | - C. Ott
- German Society of Nephrology (DGfN); Department of Nephrology and Hypertension, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
- Department of Nephrology and Hypertension, Paracelsus Medical University, Nürnberg, Germany
| | - E. Langheim
- German Society of prevention and rehabilitation of cardiovascular diseaese (DGPR), Reha Center Seehof, Teltow, Germany
| | - M. Czerny
- German Society of Thoracic and Cardiovascular Surgery (DGTHG), Department University Heart Center Freiburg – Bad Krozingen, Freiburg, Germany
- Albert Ludwigs University Freiburg, Freiburg, Germany
| | - R. Puls
- German Radiologic Society (DRG); Institute of Diagnostic an Interventional Radiology and Neuroradiology, Helios Klinikum Erfurt, Erfurt, Germany
| | - A. Maßmann
- German Society of Interventional Radiology (DeGIR); Department of Diagnostic an Interventional Radiology, Saarland University Hospital, Homburg, Germany
| | - K. Zeyer
- Marfanhilfe e. V., Weiden, Germany
| | - H. Schelzig
- German Society of Surgery (DGCH); Department of Vascular and Endovascular Surgery, University Hospital of Düsseldorf, Düsseldorf, Germany
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Nana P, Spanos K, Behrendt CA, Dakis K, Brotis A, Kouvelos G, Giannoukas A, Kölbel T. Editor's Choice - Sex Specific Outcomes After Complex Fenestrated and Branched Endovascular Aortic Repair: A Systematic Review and Meta-analysis. Eur J Vasc Endovasc Surg 2022; 64:200-208. [PMID: 35598720 DOI: 10.1016/j.ejvs.2022.05.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 04/17/2022] [Accepted: 05/13/2022] [Indexed: 01/12/2023]
Abstract
OBJECTIVE As females are at higher mortality risk after endovascular aortic repair, this study aimed to compare the 30-day and 12-month mortality, morbidity, and re-intervention rates between the sexes, treated with fenestrated or branched endovascular aortic repair (F/BEVAR). DATA SOURCES A search of the English literature, via Ovid, using MEDLINE, Embase, and CENTRAL, up to 30 July 2021, was performed. REVIEW METHODS This meta-analysis was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement, and its protocol was registered in PROSPERO (CRD42021273418). Observational studies (2010-21), with ≥ 20 patients, reporting on sex specific outcomes (mortality, acute kidney injury [AKI], spinal cord ischaemia [SCI], and re-intervention, after F/BEVAR), were considered eligible. Risk of bias in the studies was assessed using ROBINS-I, and evidence quality was assessed using GRADE. The primary outcome was the sex specific 30-day mortality rate, AKI, SCI, and re-intervention rates; secondary outcomes were survival and freedom from re-intervention at 12 months after F/BEVAR. The outcomes were summarised as odds ratio (OR) with 95% confidence intervals (CIs). RESULTS Four retrospective and one prospective study (2 421 patients; 26% females) were included. The 30-day mortality rate was 12% in females vs. 3% in males (OR 2.65, 95% CI 1.79 - 3.92; Ι2 = 0%). The 30-day AKI, SCI, and re-intervention rates were similar (OR 1.45, 95% CI 1.03 - 2.03; Ι2 = 0%; OR 1.86, 95% CI 1.27 - 2.74; Ι2 = 38%; and OR 1.06, 95% CI 0.66 - 1.77; Ι2 = 0%, respectively). The 12-month survival rate was lower in females (OR 0.95, 95% CI 0.91 - 0.99; Ι2 = 38%). When excluding 30-day deaths, there was no difference in 12-month survival between sexes (OR 0.99, 95% CI 0.95 - 1.02; Ι2 = 32%). The 12-month freedom from re-intervention was similar between sexes (OR 0.87, 95% CI 0.75 - 1.01; Ι2 = 0%). CONCLUSION Female patients treated by F/BEVAR may present worse outcomes in terms of 30-day and 12-month survival. The high peri-operative mortality rate remains an issue. When excluding 30-day deaths, the 12-month survival rate was similar between the sexes. Early morbidity and re-intervention rates were comparable.
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Affiliation(s)
- Petroula Nana
- Vascular Surgery Department, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece.
| | - Konstantinos Spanos
- Vascular Surgery Department, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; German Aortic Centre, Department of Vascular Medicine, University Heart Centre Hamburg, Hamburg, Germany
| | | | - Konstantinos Dakis
- Vascular Surgery Department, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Alexandros Brotis
- Department of Neurosurgery, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - George Kouvelos
- Vascular Surgery Department, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Athanasios Giannoukas
- Vascular Surgery Department, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Tilo Kölbel
- German Aortic Centre, Department of Vascular Medicine, University Heart Centre Hamburg, Hamburg, Germany
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Paajanen P, Kärkkäinen JM, Tenorio ER, Mendes BC, Oderich GS. Effect of patient frailty status on outcomes of fenestrated-branched endovascular aortic repair for complex abdominal and thoracoabdominal aortic aneurysms. J Vasc Surg 2022; 76:1170-1179.e2. [PMID: 35697310 DOI: 10.1016/j.jvs.2022.05.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 04/25/2022] [Accepted: 05/09/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE In the present study, we assessed the effects of patient frailty status on the early outcomes and late survival after fenestrated-branched endovascular aortic repair (FB-EVAR) for complex abdominal and thoracoabdominal aortic aneurysms. METHODS We retrospectively reviewed the clinical data and outcomes of consecutive patients who had undergone elective FB-EVAR from 2007 to 2019 in a single institution. A previously validated 11-item modified frailty index (mFI-11) was derived from the comorbidity and preoperative functional status data. An mFI-11 <0.3 was defined as low risk, 0.3 to 0.5 as medium risk, and >0.5 as high risk. The studied outcomes were 90-day mortality, major adverse events (MAE), and long-term survival. Multivariate analyses were performed to identify the independent predictors of these outcomes. RESULTS A total of 592 patients (155 women, mean age, 75 ± 8 years) had undergone FB-EVAR. Using the mFI-11, 310 patients (52%) were included in the low-risk, 199 (34%) in the medium-risk, and 83 (14%) in the high-risk group. The 90-day mortality was significantly higher in the high-risk group than in the medium- and low-risk groups (13%, 4%, and 3%, respectively; P < .01). The corresponding MAE rates were 27%, 18%, and 19% (P = .23). As a subgroup, 44 patients in the high-risk group had had chronic kidney disease (CKD). The 90-day mortality for these patients was as high as 23%, and 32% had experienced MAE. On multivariable analysis, the independent risk factors for 90-day mortality were CKD, respiratory disease, and a high mFI-11. The independent risk factors for MAE were female sex, CKD, larger aneurysm diameter, and the high-risk subgroup with CKD. The independent risk factors for long-term mortality were age, a low body mass index, CKD, larger aneurysm diameter, extent I-III thoracoabdominal aortic aneurysm, respiratory disease, congestive heart failure, a history of cerebrovascular problems, and higher mFI-11. The estimated survival at 1 year was 91% ± 2% in the low-risk, 88% ± 2% in the medium-risk, and 78% ± 5% in the high-risk group (P < .001). The corresponding 5-year survival estimates were 60% ± 4%, 52% ± 5%, and 32% ± 6%. The mean follow-up time was 2.9 ± 2.3 years. The patients treated during the first quartile of the study period were significantly more frail than were those in the later quartiles. Also, the outcomes of FB-EVAR had improved over time. CONCLUSIONS Greater frailty was significantly associated with early mortality. Together with CKD, frailty was also associated with MAE and lower patient survival after FB-EVAR. The mFI-11 represents the accumulation of comorbidities and can be used to assist in better patient selection for FB-EVAR.
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Affiliation(s)
- Paavo Paajanen
- Heart Center, Kuopio University Hospital, Kuopio, Finland
| | | | - Emanuel R Tenorio
- Division of Vascular and Endovascular Surgery, University of Texas Health Science Center, Houston, TX
| | - Bernardo C Mendes
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Gustavo S Oderich
- Division of Vascular and Endovascular Surgery, University of Texas Health Science Center, Houston, TX.
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Khan MA, Elsayed N, Naazie I, Ramakrishnan G, Kashyap VS, Malas MB. Impact of Frailty on Postoperative Outcomes in Patients undergoing TransCarotid Artery Revascularization (TCAR). Ann Vasc Surg 2022; 84:126-134. [PMID: 35247537 DOI: 10.1016/j.avsg.2021.12.085] [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: 08/30/2021] [Revised: 11/12/2021] [Accepted: 12/29/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Frailty is a clinical syndrome characterized by reduction in metabolic reserves leading to increased susceptibility to adverse outcomes following invasive surgical interventions. The 5-item modified frailty index (mFI-5) validated in prior studies has shown high predictive accuracy for all surgical specialties including vascular procedures. In this study we aim to utilize the mFI-5 to predict outcomes in Transcarotid Revascularization (TCAR). METHODS All patient who underwent TCAR from November 2016 to April 2021 in the Vascular Quality Initiative (VQI) Database were included. The mFI-5 was calculated as a cumulative score divided by 5 with 1 point each for poor functional status, presence of diabetes, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and hypertension. Patients were stratified into two groups based on prior studies: low mFI-5 (0.6) and high (≥0.6). Primary outcomes included in-hospital death, extended length of postoperative stay (> 1 day), and non-home discharge. Secondary outcomes included in-hospital stroke, transient ischemic attack (TIA), myocardial infarction (MI), and composite endpoint of stroke/death, stroke/TIA and stroke/death/MI. Univariate and multivariable logistic regression were used to assess the association between mFI-5 and postoperative outcomes. Secondary analysis stratified by symptomatic status was performed. RESULTS Out of the 17,983 patients who underwent TCAR, 4526(25.2%) had mFI-5 score of ≥0.6 and considered clinically frail. Compared to the non-frail group, frail patients were more likely to be female (38.7% vs 35.6%, p<0.001), have poor functional status (43.6 vs 8.3%, p<0.001), and present with significant comorbidities including diabetes (75.3% vs 26.1%, p<0.001), hypertension (98.9% vs 88.5%, p<0.001), CHF (52.2% vs 5.6, p<0.001), and COPD (60.3% vs 14.2%, p<0.001). They were also more likely to be active smokers (25.4% vs 20.4%, p<0.001) and symptomatic prior to intervention (28.7% vs 25.3%, p<0.001). On univariate analysis, frail patients were at significantly higher risk to experience adverse outcomes including in-hospital mortality, TIA, MI, stroke/death, stroke/TIA, stroke/death/MI, discharge to non-home facility, and extended LOS. After adjusting for potential confounders, frail patients remained at significantly higher risk of in-hospital mortality [aOR 2.26(1.41,3.61), p=0.001], TIA [aOR 1.65(1.08, 2.54), p=0.040], non-home discharge [aOR 1.99(1.71,2.32) p<0.001], and extended LOS [aOR 1.41(1.27, 1.55) p<0.001]. On further stratified analysis based on symptomatic status, the increased risk of stroke/death, TIA, and death was observed only in symptomatic patients. CONCLUSION Modified Frailty Index is a reliable tool that can be used to identify high risk patients for TCAR prior to intervention. This could help vascular surgeons, patients, and families in informed decision making to further optimize perioperative care and medical management in frail patients.
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Affiliation(s)
- Maryam Ali Khan
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, San Diego, CA
| | - Nadin Elsayed
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, San Diego, CA
| | - Isaac Naazie
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, San Diego, CA
| | - Ganesh Ramakrishnan
- Department of Surgery, Temple University School of Medicine, Philadelphia, PA
| | - Vikram S Kashyap
- Division of Vascular and Endovascular Surgery, Department of Surgery, University Hospital Case Medical Center, Cleveland, OH
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, San Diego, CA.
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Edman NI, Zettervall SL, Dematteis MN, Ghaffarian A, Shalhub S, Sweet MP. Women with Thoracoabdominal Aortic Aneurysms Have Increased Frailty and More Complex Aortic Anatomy Compared with Men. J Vasc Surg 2022; 76:61-69.e3. [DOI: 10.1016/j.jvs.2022.01.145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 01/31/2022] [Indexed: 10/19/2022]
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18
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Tse W, Lavingia KS, Amendola MF. Using the risk analysis index to assess frailty in a veteran cohort undergoing endovascular aortic aneurysm repair. J Vasc Surg 2021; 75:1591-1597.e1. [PMID: 34793920 DOI: 10.1016/j.jvs.2021.10.049] [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: 06/09/2021] [Accepted: 10/25/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Surgical frailty is strongly associated with increased perioperative morbidity and mortality. The risk analysis index (RAI) is a validated frailty score system, which has been shown to predict for short-term outcomes and long-term mortality in various surgical subspecialties. In the present study, we applied the frailty score to a veteran aneurysm population who had undergone nonemergent endovascular aortic aneurysm repair (EVAR). METHODS After obtaining institutional review board approval, the Veteran Affairs Surgical Quality Improvement Program data were queried for endovascular repair of infrarenal abdominal aortic aneurysm or dissection using the Current Procedural Terminology codes 34,800, 34,803, and 34,805 from 2001 to 2018. The preoperative variables were used to calculate the RAI score. The patients were placed into six cohorts according to the RAI score (≤20, 21-25, 26-30, 31-35, 35-40, and ≥41). The χ2 test and analysis of variance test were used compare the cohorts. Forward logistic regression modeling was used to determine the risks of each cohort. RESULTS From 2001 to 2018, 5568 patients had undergone EVAR. Of the 5568 patients, 99.6% were male, with a mean age of 71 ± 8 years. Of these patients, 4.5%, 43.8%, 33.9%, 11.7%, 4.2%, and 1.8% were included in the following RAI groups: ≤20, 21 to 25, 26 to 30, 31 to 35, 35 to 40, and ≥41, respectively. Frailty was associated with increased rates of overall complications, death, and an increased length of stay. When risk adjusted, frailty at the highest vs lowest level was associated with 2.7 times the odds of any complication developing and 4.4 times the odds of mortality ≤30 days. CONCLUSIONS Frailty, as determined by the RAI, was associated with postoperative outcomes in a dose-dependent manner. Frailty was associated with higher rates of major cardiac (myocardial infarction, cardiac arrest), pulmonary (pneumonia, failure to wean from ventilation, reintubation), renal (renal failure), overall complications, length of stay, and death. We recommend the use of this frailty index as a screening tool to guide discussions with patients scheduled to undergo EVAR.
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Affiliation(s)
- Wayne Tse
- Department of Surgery, Virginia Commonwealth University Health Systems, Richmond, Va; Department of Surgery, Central Virginia Veterans Affairs Health System, Richmond, Va
| | - Kedar S Lavingia
- Department of Surgery, Virginia Commonwealth University Health Systems, Richmond, Va; Department of Surgery, Central Virginia Veterans Affairs Health System, Richmond, Va.
| | - Michael F Amendola
- Department of Surgery, Virginia Commonwealth University Health Systems, Richmond, Va; Department of Surgery, Central Virginia Veterans Affairs Health System, Richmond, Va
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Rao A, Mehta A, Lazar AN, Siracuse J, Garg K, Schermerhorn M, Takayama H, Patel VI. The Association Between Preoperative Independent Ambulatory Status and Outcomes After Open Abdominal Aortic Aneurysm Repairs. Ann Vasc Surg 2021; 81:70-78. [PMID: 34785339 DOI: 10.1016/j.avsg.2021.10.050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Revised: 10/17/2021] [Accepted: 10/18/2021] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Preoperative functional status is appreciated as a key determinant of decision-making when evaluating patients for complex elective surgeries. We used the Vascular Quality Initiative (VQI) to analyze the effect of being able to independently ambulate on outcomes after open abdominal aortic aneurysm (AAA) repairs. METHODS We identified all patients who underwent elective or urgent open AAA repairs from January 2013 to August 2019 in the VQI registry. We recorded demographic variables, comorbidities, and operative factors such as approach, operative ischemia time, proximal clamp site, and presence of iliac aneurysms. Short-term and long-term outcomes included 30-day mortality, any perioperative complications, failure to rescue (defined as death after a complication), and one-year all-cause mortality. We dichotomized patients based on their ability to independently ambulate (Ambulatory) or inability to ambulate independently (Non-Ambulatory) and used both multivariable logistic regressions and cox-proportional hazards models to evaluate outcomes. RESULTS Of 5,371 patients, 328 (6.1%) could not ambulate independently and were more likely to be older (median age 69 vs 72), female (25% vs. 38%), and have greater comorbidities. Overall outcomes were: 4.3% for 30-day mortality, 38.7% for complications, 10.2% for failure-to-rescue, and 6.9% for one-year mortality. Univariate analysis showed higher rates of all adverse outcomes in non-ambulatory patients. On adjusted analysis, non-ambulatory patients had increased odds of complications by 46% (OR 1.46 [95%-CI 1.11-1.91]) and one-year mortality by 46% (HR 1.46 [95%-CI 1.06-1.99]), but not failure to rescue (OR 1.05 [95%-CI 0.67-1.62]) or 30-day mortality (OR 1.22 [95%-CI 0.82-1.81]). Increased hospital volume, age, and increased operative renal ischemia time were independently associated with adverse outcomes. CONCLUSIONS Non-ambulatory status was observed in a small percentage of patients undergoing open AAA repair but was associated with higher rates of post-operative complications and one-year mortality. Ambulatory capacity is one of the key determinants of outcomes following open AAA repair. In patients with poor ambulatory function, a conservative approach is highly recommended over invasive open surgical intervention.
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Affiliation(s)
- Abhishek Rao
- Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, Columbia University Medical Center, 161 Fort Washington Avenue, New York, NY, 10032 (USA)
| | - Ambar Mehta
- Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, Columbia University Medical Center, 161 Fort Washington Avenue, New York, NY, 10032 (USA)
| | - Andrew N Lazar
- Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, Columbia University Medical Center, 161 Fort Washington Avenue, New York, NY, 10032 (USA).
| | - Jeffrey Siracuse
- Division of Vascular and Endovascular Surgery, Boston Medical Center, 732 Harrison Avenue, 3(rd) Floor, Boston, MA, 02118 (USA)
| | - Karan Garg
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University, 530 1(st) Avenue, 11(th) Floor, New York, NY, 10016 (USA)
| | - Marc Schermerhorn
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis Street, STE 5B, Boston, MA, 02215 (USA)
| | - Hiroo Takayama
- Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, Columbia University Medical Center, 161 Fort Washington Avenue, New York, NY, 10032 (USA)
| | - Virendra I Patel
- Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, Columbia University Medical Center, 161 Fort Washington Avenue, New York, NY, 10032 (USA)
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20
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Nóbrega L, Pereira-Neves A, Duarte-Gamas L, Dias PP, Azevedo-Cerqueira A, Ribeiro H, Vidoedo J, Teixeira J, Rocha-Neves J. Outcome Analysis Using the Modified Frailty Index-5 in Patients With Complex Aortoiliac Disease. Ann Vasc Surg 2021; 79:153-161. [PMID: 34644633 DOI: 10.1016/j.avsg.2021.06.049] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 06/27/2021] [Accepted: 06/30/2021] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Vascular surgery patients commonly have several comorbidities that cumulatively lead to a frailty status. The cumulative comorbidities disproportionately increase the risk of adverse events and are also associated with worsened long-term prognosis. In recent years, several tools have been elaborated with the objective of quantifying a patient's frailty. One of them is the modified frailty index-5 (mFI-5), a simplified and easy to use index. There is scarce data regarding its value as a prognostic factor in aortoiliac occlusive disease. The aim of this work is to validate mFI-5 as a potential postoperative prognostic indicator in this population. METHODS From January 2013 to January 2020, 109 patients who underwent elective revascularizations, either endovascular or open surgery, having Trans-Atlantic Inter-Society Consensus II type D aortoiliac lesions in a tertiary and a regional hospital were selected from a prospective vascular registry. Demographic data was collected including diabetes mellitus, chronic heart failure, chronic obstructive pulmonary disease, arterial hypertension requiring medication and functional status. The 30-d and subsequent long-term surveillance outcomes were also collected including major adverse cardiovascular events (MACE), major adverse limb events (MALE) and all-cause mortality were assessed in the 30-d post-procedure and in the subsequent long-term surveillance period. The mFI-5 was applied to this population to evaluate the prognostic impact of this frailty marker on mortality and morbidity. RESULTS In the long-term follow-up, mFI-5 was significantly associated with MACE (hazard ratio [HR] 2.469; 95% confidence interval [CI]: 1.267-4.811; P = .008) and all-cause mortality (HR 2.585; 95% CI: 1.270-5.260; P = .009). However, there was no significant association with 30-day outcomes. Along with the presence of chronic kidney disease, mFI-5 was the prognostic factor better able of predicting MACE. No prognostic value was found regarding short-term outcomes. CONCLUSION The mFI-5 index may have a role in predicting long term outcomes, namely MACE and all-cause mortality, in the subset of patients with extensive aortoiliac occlusive disease. Its ease of use can foster its application in risk stratification and contribute for the decision-making process.
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Affiliation(s)
- Leandro Nóbrega
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal; Department of Surgery and Physiology, Faculdade de Medicina da Universidade do Porto, Porto, Portugal.
| | - António Pereira-Neves
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal; Department of Biomedicine - Unit of Anatomy, Faculdade de Medicina da Universidade do Porto, Porto, Portugal; Department of Surgery and Physiology, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - Luís Duarte-Gamas
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal; Department of Surgery and Physiology, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - Pedro Paz Dias
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal; Department of Surgery and Physiology, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - Ana Azevedo-Cerqueira
- Unidade de Saúde Familiar Odisseia, Agrupamento de Centros de Saúde Grande Porto III, Porto, Portugal
| | - Hugo Ribeiro
- Unidade de Saúde Familiar Barão Do Corvo, Agrupamento de Centros de Saúde de Gaia, Porto, Portugal; Equipa Comunitária de Suporte Em Cuidados Paliativos de Vila Nova de Gaia, Porto, Portugal
| | - José Vidoedo
- Department of Angiology and Vascular Surgery, Centro Hospitalar Tâmega e Sousa, Penafiel, Portugal
| | - José Teixeira
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - João Rocha-Neves
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal; Department of Biomedicine - Unit of Anatomy, Faculdade de Medicina da Universidade do Porto, Porto, Portugal; Department of Surgery and Physiology, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
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Shih CW, Ho ST, Shui HA, Tang CT, Shih CC, Chen TJ, Lin KC, Liang CY, Wang KY. Endovascular aortic repair is a cost-effective option for in-hospital patients with abdominal aortic aneurysm. J Chin Med Assoc 2021; 84:890-899. [PMID: 34261982 DOI: 10.1097/jcma.0000000000000581] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
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.
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Affiliation(s)
- Chia-Wen Shih
- Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan, ROC
- Department of Nursing, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Shung-Tai Ho
- Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan, ROC
- Department of Anesthesiology, Kaohsiung Medical University Chung-Ho Memorial Hospital, Kaohsiung, Taiwan, ROC
| | - Hao-Ai Shui
- Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Chi-Tun Tang
- Department of Neurological Surgery, National Defense Medical Center, Tri-Service General Hospital, Taipei, Taiwan, ROC
| | - Chun-Che Shih
- Taipei Heart Institute, Taipei Medical University, Division of Cardiovascular Surgery, Taipei, Taiwan, ROC
- Department of Surgery, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan, ROC
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Tzeng-Ji Chen
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Family Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Kuan-Chia Lin
- Institute of Hospital and Health Care Administration, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Community Medicine Research Center, Taipei, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Chun-Yu Liang
- School of Nursing, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Kwua-Yun Wang
- Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan, ROC
- Department of Nursing, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Nursing, National Defense Medical Center, Taipei, Taiwan, ROC
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22
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Tumer NB, Askin G, Akkaya BB, Civelek I, Unal EU, Iscan HZ. Outcomes after EVAR in females are similar to males. BMC Cardiovasc Disord 2021; 21:301. [PMID: 34130661 PMCID: PMC8207773 DOI: 10.1186/s12872-021-02114-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Accepted: 06/07/2021] [Indexed: 01/15/2023] Open
Abstract
Introduction Women are less likely to develop infrarenal abdominal aortic aneurysm; however, when they do, it is almost always associated with challenging anatomy, more rapid aneurysmal growth rate and earlier rupture. Women generally have poorer outcomes following open aneurysm repair; and in this respect, the present study aims to evaluate if it is so after endovascular repair.
Methods A retrospective analysis of our database was performed for patients underwent endovascular aneurysm repair (EVAR) between January 2013–March 2020. 249 elective EVAR patients were evaluated. Patients were categorized according to gender and 26 patients (10.4%) were female. Demographics and pre-peri-postoperative findings were compared. Propensity score matching (ratio 1:1) was performed to reduce selection bias.
Results In the overall unmatched cohort, female population had more diabetes mellitus (p = 0.016) and hypertension (p = 0.005). However, coronary artery disease (p = 0.005) and coronary artery bypass grafting (p = 0.006) were more in male gender. Non-IFU implantation was higher in female group (38.5% vs. 11.5%, p = 0.025). After propensity matching, even though it was not statistically significant, early mortality for female gender was higher when compared to male gender (7.7% and 0%, respectively, p = 0.490). In the follow-up period, no difference in all-cause mortality, secondary interventions or complications have been observed between the genders. Conclusion Challenging anatomy and subsequently treated patients outside IFU may be the reasons for higher morbidity and mortality in women. However, despite these factors female and male patients revealed equivalent early and late results.
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Affiliation(s)
- Naim Boran Tumer
- Department of Cardiovascular Surgery, Ankara City Hospital, Ankara, Turkey.
| | - Goktan Askin
- Department of Cardiovascular Surgery, Ankara City Hospital, Ankara, Turkey
| | | | - Isa Civelek
- Department of Cardiovascular Surgery, Ankara City Hospital, Ankara, Turkey
| | - Ertekin Utku Unal
- Department of Cardiovascular Surgery, Hitit University Erol Olcok Training and Research Hospital, Çorum, Turkey
| | - Hakki Zafer Iscan
- Department of Cardiovascular Surgery, Ankara City Hospital, Ankara, Turkey
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D'Oria M, Ziani B, Damiano Pipitone M, Manganotti P, Mucelli RP, Gorgatti F, Riccitelli F, Zamolo F, Fisicaro M, Lepidi S. Prognostic interaction between age and sex on outcomes following carotid endarterectomy. VASA 2021; 50:453-461. [PMID: 34102866 DOI: 10.1024/0301-1526/a000957] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Background: The aim of this study was to assess the prognostic interaction between age and sex on peri-operative and follow-up outcomes following elective carotid endarterectomy (CEA) for asymptomatic and symptomatic carotid stenosis. Patients and methods: A retrospective review of all patients admitted to a single vascular unit who underwent elective CEA between January, 2015 and December, 2019 was performed. The primary endpoints of the study were overall survival (from index operation) and cumulative stroke rate at thirty days. Results: A total of 383 consecutive patients were included in this study; of these 254 (66.4%) were males. At baseline, males were younger (mean age 73.4±11 vs. 76.3±10 years, p=.01) and with lower proportion of octogenarians (20.4% vs. 28.7%, p=.05). The rate of stroke in symptomatic and asymptomatic patients (males vs. females) were as follows: a) whole cohort 1.9% vs. 2% (p=1.00) and 2.7% vs. 1.3% (p=.66), respectively; b) ≥80 years old 3.7% vs. 0% (p=1.00) and 4% vs. 5.9% (p=1.00), respectively; c) <80 years old 1.2% vs. 3.3% (p=.47) and 2.5% vs. 0% (p=.55), respectively. The 3-year survival estimates were significantly lower for males (84% vs. 92%, p=.03). After stratification by age groups, males maintained inferior survival rates in the strata aged <80 years (85% vs. 97%, p=.005), while no differences were seen in the strata aged ≥80 years (82% vs. 79%, p=.92). Using multivariate Cox proportional hazards, age (HR: 2.1, 95% CI: 1.29-3.3, p=.002) and male gender (HR: 2.5, 95% CI: 1.16-5.5, p=.02) were associated with increased hazards of all-cause mortality. Conclusions: In this study of elective CEA for asymptomatic and symptomatic carotid stenosis, similar peri-operative neurologic outcomes were found in both males and females irrespective of age. Despite being usually older, females have superior long-term survival rates.
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Affiliation(s)
- Mario D'Oria
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, Cattinara University Hospital ASUGI, Trieste, Italy
| | - Barbara Ziani
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, Cattinara University Hospital ASUGI, Trieste, Italy
| | | | - Paolo Manganotti
- Clinical Unit of Neurology, Department of Medicine Surgery and Health Sciences, Cattinara University Hospital ASUGI, Trieste, Italy
| | - Roberta Pozzi Mucelli
- Radiology Unit, Department of Medicine Surgery and Health Sciences, Cattinara University Hospital ASUGI, Trieste, Italy
| | - Filippo Gorgatti
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, Cattinara University Hospital ASUGI, Trieste, Italy
| | - Francesco Riccitelli
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, Cattinara University Hospital ASUGI, Trieste, Italy
| | - Francesca Zamolo
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, Cattinara University Hospital ASUGI, Trieste, Italy
| | - Maurizio Fisicaro
- Cardiovascular Health Services Centre, Cardiovascular Department, Maggiore Hospital ASUGI, Trieste, Italy
| | - Sandro Lepidi
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, Cattinara University Hospital ASUGI, Trieste, Italy
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Alkadri J, Hage D, Nickerson LH, Scott LR, Shaw JF, Aucoin SD, McIsaac DI. A Systematic Review and Meta-Analysis of Preoperative Frailty Instruments Derived From Electronic Health Data. Anesth Analg 2021; 133:1094-1106. [PMID: 33999880 DOI: 10.1213/ane.0000000000005595] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Frailty is a strong predictor of adverse outcomes in the perioperative period. Given the increasing availability of electronic medical data, we performed a systematic review and meta-analysis with primary objectives of describing available frailty instruments applied to electronic data and synthesizing their prognostic value. Our secondary objectives were to assess the construct validity of frailty instruments that have been applied to perioperative electronic data and the feasibility of electronic frailty assessment. METHODS Following protocol registration, a peer-reviewed search strategy was applied to Medline, Excerpta Medica dataBASE (EMBASE), Cochrane databases, and the Comprehensive Index to Nursing and Allied Health literature from inception to December 31, 2019. All stages of the review were completed in duplicate. The primary outcome was mortality; secondary outcomes included nonhome discharge, health care costs, and length of stay. Effect estimates adjusted for baseline illness, sex, age, procedure, and urgency were of primary interest; unadjusted and adjusted estimates were pooled using random-effects models where appropriate or narratively synthesized. Risk of bias was assessed. RESULTS Ninety studies were included; 83 contributed to the meta-analysis. Frailty was defined using 22 different instruments. In adjusted data, frailty identified from electronic data using any instrument was associated with a 3.57-fold increase in the odds of mortality (95% confidence interval [CI], 2.68-4.75), increased odds of institutional discharge (odds ratio [OR], 2.40; 95% CI, 1.99-2.89), and increased costs (ratio of means, 1.54; 95% CI, 1.46-1.63). Most instruments were not multidimensional, head-to-head comparisons were lacking, and no feasibility data were reported. CONCLUSIONS Frailty status derived from electronic data provides prognostic value as it is associated with adverse outcomes, even after adjustment for typical risk factors. However, future research is required to evaluate multidimensional instruments and their head-to-head performance and to assess their feasibility and clinical impact.
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Affiliation(s)
- Jamal Alkadri
- From the Department of Anesthesiology & Pain Medicine
| | - Dima Hage
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Lia R Scott
- Department of General Surgery, Queen's University, Ottawa, Ontario, Canada
| | - Julia F Shaw
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Daniel I McIsaac
- From the Department of Anesthesiology & Pain Medicine.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Nadeswaran P, Ding L, Singh N, Plotkin A, Magee GA, Han SM, Garg PK. Functional performance status and risk of cardiovascular events and mortality following endovascular repair of thoracic and abdominal aortic pathology. Vascular 2021; 30:206-216. [PMID: 33900842 DOI: 10.1177/17085381211010545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To characterize the association of preoperative functional performance status based on Eastern Cooperative Oncology Group (ECOG) scoring with the risk of adverse cardiovascular events, vascular events, and mortality in patients undergoing EVAR and TEVAR. METHODS Retrospective review of the Society for Vascular Surgery Vascular Quality Initiative, a large, multi-center, registry database was performed. All individuals undergoing EVAR (n = 18,730) and TEVAR (n = 6595) for non-ruptured aortic pathologies between 2014 and 2018 were eligible for analysis. Multivariable logistic regression was used to determine the association of pre-procedure ECOG functional performance status on risk of in-hospital adverse cardiovascular events, vascular events, and mortality. RESULTS The number of operations complicated by adverse cardiovascular and vascular events was 480 (2.6%) and 190 (1.0%) for EVAR and 733 (11.1%) and 219 (3.3%) for TEVAR, respectively. There were 118 (0.6%) and 240 (3.6%) in-hospital deaths following EVAR and TEVAR, respectively. Patients with ECOG grades 3 or 4 undergoing EVAR were at increased risk of cardiovascular events (OR = 1.62; 95% CI = 1.09, 2.41) and one-year mortality (HR = 2.62; 95% CI = 1.92, 3.57) compared to those with ECOG grade 0. Patients undergoing TEVAR with ECOG grade 3 or 4 were at increased risk for both inpatient death (OR = 2.77; 95% CI = 1.56, 4.9) and one-year mortality (HR = 3.27, 95% CI = 2.06, 5.21). ECOG status was not associated with an increased risk of adverse vascular events following either EVAR or TEVAR. CONCLUSIONS Poor preoperative functional status as assessed by ECOG score is associated with an increased risk of adverse postoperative cardiovascular events following EVAR and a higher mortality risk following both EVAR and TEVAR. Functional status assessment may be useful for risk stratification and determining procedural candidacy prior to EVAR and TEVAR.
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Affiliation(s)
- Pradeep Nadeswaran
- Division of Cardiology, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Li Ding
- Department of Preventive Medicine, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Nikhil Singh
- Section of Cardiology, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Anastasia Plotkin
- Division of Vascular Surgery and Endovascular Therapy, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Gregory A Magee
- Division of Vascular Surgery and Endovascular Therapy, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Sukgu M Han
- Division of Vascular Surgery and Endovascular Therapy, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Parveen K Garg
- Division of Cardiology, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
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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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Popova IV, Ignatenko PV, Rabtsun AA, Saaia SB, Bugurov SV, Soborov MA, Popov VV, Diusupov AA, Karpenko AA. [Outcomes of endoprosthetic repair of abdominal aortic aneurysm]. ANGIOLOGIIA I SOSUDISTAIA KHIRURGIIA = ANGIOLOGY AND VASCULAR SURGERY 2021; 27:59-69. [PMID: 35050250 DOI: 10.33529/angio2021402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
AIM The study was aimed at assessing efficacy and safety of endovascular treatment of abdominal aortic aneurysms based on 11-year experience with implantation of stent grafts. PATIENTS AND METHODS We retrospectively analysed outcomes of treatment of 242 patients with abdominal aortic aneurysm during the period from 2008 to 2019. Of these, 210 (86.78%) were males, mean age 69.32±7.36 years. Diagnosis was made using colour duplex scanning and contrast-enhanced multislice spiral computed tomography, with implanting the following stent grafts: Ella - 44, Ovation Prime - 33, Anaconda - 13, Endurand - 77, Aortix - 2, Zenith - 33, Seal - 39, with one endoprosthesis placement failed. Assessing safety of the operation, we took into consideration lethality due to aortic rupture/thrombosis. Efficacy was taken to mean technical success of the operation (implantation of all components of the endograft without switch to open surgery), the number of reoperations. RESULTS Technical success of the operation was achieved in 98.35% of cases. In 1 case due to pronounced arterial calcification for technical reasons we failed to position the stent graft and in another case - the contralateral leg of the Ella prosthesis. The early postoperative period revealed: type A1 endoleak - 3.7%, type IB - 4.13%, type IIA - 6.6%, type IIB - 4.54%, type III - 0.83%, type IV - 0.83%. Repeat operations were performed in 20 (8.2%) patients within 30 days after the intervention and in 32 (13.22%) in the remote period. In the early postoperative period two conversions were performed: 1) iliorenal bypass grafting for restoration of blood flow through the renal artery occluded by endoprosthesis wall; 2) evacuation of retroperitoneal haematoma due to rupture of the common femoral artery. Lethality during the whole period of follow up amounted to 32 (13.22%) cases. Of these, due to aortic complications 4.54% (n=11) and due to accompanying pathology 8.67% (n=21). A direct correlation was revealed between the aortic diameter and duration of the operation which in turn increases the risk of complications requiring re-operation or resulting in a lethal outcome (RR - 1; 95% CD 1- 1; p=0.026). CONCLUSION Our experience showed high safety and efficacy of stent graft implantation in treatment of patients with abdominal aortic aneurysms and high surgical risk.
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Affiliation(s)
- I V Popova
- Cardiosurgical Department of Vascular Pathology and Hybrid Technologies, Centre of Vascular and Hybrid Surgery, Meshalkin National Medical Research Centre of the RF Ministry of Public Health, Novosibirsk, Russia
| | - P V Ignatenko
- Cardiosurgical Department of Vascular Pathology and Hybrid Technologies, Centre of Vascular and Hybrid Surgery, Meshalkin National Medical Research Centre of the RF Ministry of Public Health, Novosibirsk, Russia
| | - A A Rabtsun
- Cardiosurgical Department of Vascular Pathology and Hybrid Technologies, Centre of Vascular and Hybrid Surgery, Meshalkin National Medical Research Centre of the RF Ministry of Public Health, Novosibirsk, Russia
| | - Sh B Saaia
- Cardiosurgical Department of Vascular Pathology and Hybrid Technologies, Centre of Vascular and Hybrid Surgery, Meshalkin National Medical Research Centre of the RF Ministry of Public Health, Novosibirsk, Russia
| | - S V Bugurov
- Cardiosurgical Department of Vascular Pathology and Hybrid Technologies, Centre of Vascular and Hybrid Surgery, Meshalkin National Medical Research Centre of the RF Ministry of Public Health, Novosibirsk, Russia
| | - M A Soborov
- Department of Hospital Surgery, Sechenov First Moscow State Medical University of the RF Ministry of Public Health, Moscow, Russia
| | - V V Popov
- Department of Surgical Diseases, Novosibirsk National Research State University, Novosibirsk, Russia
| | - A A Diusupov
- Department of Cardiovascular and Thoracic Surgery, Semey Medical University, Semey, Kazakhstan
| | - A A Karpenko
- Cardiosurgical Department of Vascular Pathology and Hybrid Technologies, Centre of Vascular and Hybrid Surgery, Meshalkin National Medical Research Centre of the RF Ministry of Public Health, Novosibirsk, Russia
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Banning LBD, El Moumni M, Visser L, van Leeuwen BL, Zeebregts CJ, Pol RA. Frailty leads to poor long-term survival in patients undergoing elective vascular surgery. J Vasc Surg 2020; 73:2132-2139.e2. [PMID: 33387657 DOI: 10.1016/j.jvs.2020.10.088] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 10/29/2020] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Frailty has persistently been associated with unfavorable short-term outcomes after vascular surgery, including an increased complication risk, greater readmission rate, and greater short-term mortality. However, a knowledge gap remains concerning the association between preoperative frailty and long-term mortality. In the present study, we aimed to determine this association in elective vascular surgery patients. METHODS The present study was a part of a large prospective cohort study initiated in 2010 in our tertiary referral teaching hospital to study frailty in elderly elective vascular surgery patients (Vascular Ageing Study). A total of 639 patients with a minimal follow-up of 5 years, who had been treated from 2010 to 2014, were included in the present study. The Groningen Frailty Indicator, a 15-item self-administered questionnaire, was used to determine the presence and degree of frailty. RESULTS Of the 639 patients, 183 (28.6%) were considered frail preoperatively. For the frail patients, the actuarial survival after 1, 3, and 5 years was 81.4%, 66.7%, and 55.7%, respectively. For the nonfrail patients, the corresponding survival was 93.6%, 83.3%, and 75.2% (log-rank test, P < .001). Frail patients had a significantly greater risk of 5-year mortality (unadjusted hazard ratio, 2.09; 95% confidence interval, 1.572-2.771; P < .001). After adjusting for surgical- and patient-related risk factors, the hazard ratio was 1.68 (95% confidence interval, 1.231-2.286; P = .001). CONCLUSIONS The results of our study have shown that preoperative frailty is associated with significantly increased long-term mortality after elective vascular surgery. Knowledge of a patient's preoperative frailty state could, therefore, be helpful in shared decision-making, because it provides more information about the procedural benefits and risks.
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Affiliation(s)
- Louise B D Banning
- Division of Vascular Surgery, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Mostafa El Moumni
- Division of Trauma Surgery, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Linda Visser
- Division of Vascular Surgery, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Barbara L van Leeuwen
- Division of Surgical Oncology, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Clark J Zeebregts
- Division of Vascular Surgery, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Robert A Pol
- Division of Vascular Surgery, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
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Frailty and hypertension in older adults: current understanding and future perspectives. Hypertens Res 2020; 43:1352-1360. [PMID: 32651557 DOI: 10.1038/s41440-020-0510-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 06/12/2020] [Accepted: 06/16/2020] [Indexed: 12/17/2022]
Abstract
Hypertension is an important factor affecting the health of older adults. Antihypertensives can reduce stroke, cardiovascular events, and mortality in older hypertensive patients. Blood pressure management is difficult in older adults since geriatric syndromes such as frailty and comorbidities often coexist with hypertension. Recent guidelines propose taking functional status into account when targeting blood pressure in older people. Therefore, a better understanding and control of frailty risk factors could improve the prognosis of older adults with hypertension. However, there are relatively few studies on hypertension and frailty in older adults, especially studies focused on antihypertensive treatment. The goals, target values, and choice of antihypertensive treatment for frail older adults are still disputed. We reviewed the recent literature focusing on frailty and hypertension in older adults and propose a management process for screening and assessing frailty and hypertension before the use of antihypertensives. The process can support older adults with lifestyle interventions and frailty management and help them begin taking a single antihypertensive medication.
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Reeve TE, Craven TE, Goldman MP, Hurie JB, Velazquez-Ramirez G, Edwards MS, Corriere MA. Outpatient grip strength measurement predicts survival, perioperative adverse events, and nonhome discharge among patients with vascular disease. J Vasc Surg 2020; 73:250-257. [PMID: 32360376 DOI: 10.1016/j.jvs.2020.03.060] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 03/20/2020] [Indexed: 01/24/2023]
Abstract
OBJECTIVES Frailty is associated with adverse outcomes among patients with vascular disease. Grip strength measurement is a comparatively simple, quick, and inexpensive screening test for weakness (a component of frailty) that is potentially applicable to clinical practice. We hypothesized that grip strength and categorical weakness are associated with clinical outcomes among patients with vascular disease. To test this hypothesis, we conducted a longitudinal cohort study evaluating associations between grip strength measured during outpatient clinic visits for vascular disease and clinical outcomes, including survival and perioperative outcomes. METHODS Adult patients recruited from outpatient vascular surgery and/or vascular medicine clinics underwent dominant hand grip strength measurement using a hand dynamometer. Participants were categorized as weak based on grip strength, sex, and body mass index. Multivariable logistic models were used to evaluate perioperative outcomes. Mortality was evaluated using Cox proportional hazards models adjusted for sex, age, and operative intervention during follow-up. RESULTS We enrolled 321 participants. The mean patients age was 69.0 ± 9.4 years, and 33% were women. Mean grip strength was 32.0 ± 12.1 kg, and 92 participants (29%) were categorized as weak. The median follow-up was 24.0 months. Adverse perioperative events occurred in 32 of 84 patients undergoing procedures. Grip strength was associated with decreased risk of perioperative adverse events (hazard ratio [HR], 0.41 per 12.7 kg increase; 95% confidence interval [CI], 0.20-0.85; P = .0171) in a model adjusted for open versus endovascular procedure (HR, 12.75 for open; 95% CI, 2.54-63.90; P = .0020) and sex (HR, 3.05 for male; 95% CI, 0.75-12.4; P = .120). Grip strength was also associated with a lower risk of nonhome discharge (HR, 0.34 per 12.7 kg increase; 95% CI, 0.14-0.82; P = .016) adjusted for sex (HR, 2.14 for male; 95% CI, 0.48-9.50; P = .31) and open versus endovascular procedure (HR, 10.36 for open; 95% CI, 1.20-89.47; P = .034). No associations between grip strength and length of stay were observed. Mortality occurred in 48 participants (14.9%) during follow-up. Grip strength was inversely associated with mortality (HR, 0.46 per 12.5 kg increase; 95% CI, 0.29-0.73; P = .0009) in a model adjusted for sex (HR, 5.08 for male; 95% CI, 2.1-12.3; P = .0003), age (HR, 1.04 per year; 95% CI, 1.01-1.08), and operative intervention during follow-up (HR, 1.23; 95% CI, 0.71-2.52). Categorical weakness was also associated with mortality (HR, 1.81 vs nonfrail; P = .048) in a model adjusted for age (HR, 1.06 per year; P = .002) and surgical intervention (HR, 1.36; 95% CI, 1.02-0.09; P = .331). CONCLUSIONS Grip strength is associated with all-cause mortality, perioperative adverse events, and nonhome discharge among patients with vascular disease. These observations support the usefulness of grip strength as a simple and inexpensive risk screening tool for patients with vascular disease.
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Affiliation(s)
- Thomas E Reeve
- Department of Vascular and Endovascular Surgery, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Timothy E Craven
- Department of Biostatistical Sciences, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Matthew P Goldman
- Department of Vascular and Endovascular Surgery, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Justin B Hurie
- Department of Vascular and Endovascular Surgery, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Gabriela Velazquez-Ramirez
- Department of Vascular and Endovascular Surgery, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Matthew S Edwards
- Department of Vascular and Endovascular Surgery, Wake Forest University School of Medicine, Winston-Salem, NC
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