The aim of this study was to assess cardiovascular predictors for all-cause long-term mortality in patients undergoing standard endovascular aneurysm repair (EVAR) for infrarenal abdominal aortic aneurysm (AAA). Consecutive patients treated with EVAR (Zenith(®) stent grafts; Cook) between May 1998 and February 2006 were prospectively enrolled in a computerized database, together with retrospectively collected data on medication, and electrocardiographic and echocardiographic variables. Mortality was assessed on 1 December 2010. The median follow-up time was 68 months and the median age was 74 years (range 53-89) for the 304 patients. Mortality at the end of follow-up was 54.3% (165/304). The proportion of deaths caused by vascular diseases was 61% (101/165). In the univariate analysis, low preoperative ejection fraction (EF) (p = 0.004), absence of statin medication (p = 0.007), and medication with diuretics (p = 0.028) or digitalis (p = 0.016) were associated with an increased long-term mortality rate. Myocardial ischemia on electrocardiogram (ECG) (hazard ratio (HR) 1.6 [95% CI 1.1-2.4]) and anemia (HR 1.5 [95% CI 1.0-2.1]) were found to be independent predictors for long-term mortality after Cox regression analysis. There was a trend that chronic kidney disease, stage = 3 (HR 1.5 [95% CI 1.0-2.2]), and age 80 years and above (HR 1.5 [95% CI 1.0-2.4]) were independently associated with long-term mortality. In conclusion, ischemia on ECG and anemia were independently related to an increased long-term mortality rate after EVAR, and these predictive factors seem to be most important for critical assessment in the preoperative medical work-up.
Aneurysm repair is centralized in higher volume centers resulting in reduced mortality, with longer travel distances. The purpose of this study is to explore patients' preference between local care versus longer distances and lower mortality rates.
Patients with abdominal aortic aneurysm (AAA) measuring 4 to 5 cm and living at least a 1-hour drive from our hospital were asked to assume it had grown to 5.5 cm, and repair was recommended with a mortality risk of 2%. The level of additional risk they would accept to undergo surgery locally was determined.
A total of 67 patients were surveyed. If mortality risk was equivalent at the local and regional hospitals, 44% preferred care at our tertiary center, while 56% preferred surgery locally. If perioperative mortality was increased at the local hospital, 9% preferred local surgery.
The vast majority of patients with AAA will accept longer travel distances for care as long as it results in a reduction in perioperative mortality.
In randomized trials, no peri-operative survival benefit has been shown for endovascular (EVAR) repair of ruptured abdominal aortic aneurysm (rAAA) when compared with open repair. The aim of this study was to investigate the effect of primary repair strategy on early and midterm survival in a non-selected population based study.
The Swedish Vascular Registry was consulted to identify all rAAA repairs performed in Sweden in the period 2008-12. Centers with a primary EVAR strategy (treating > 50% of rAAA with EVAR) were compared with centers with a primary open repair strategy. Peri-operative outcome, midterm survival, and incidence of rAAA repair/100,000 inhabitants aged > 50 years were assessed.
In total, 1,304 patients were identified. Three primary EVAR centers (pEVARc) operated on 236 patients (74.6% EVAR). Twenty-six primary open repair centers (pORc) operated 1,068 patients (15.6% EVAR). Patients treated at pEVARc were more often referrals (28.0% vs. 5.3%; p
International comparison of registry data within vascular surgery has previously been published by Vascunet. One of the limitations of such comparisons is data validity and completeness, and meaningful interpretation of differences between countries can only be made if the data are robust within each of the countries studied. The Vascunet collaboration has therefore embarked on a validation exercise of international vascular registry data.
Five out of 20 hospitals performing vascular surgery in Sweden were visited by two international validators. Independent evaluation of the procedures of carotid endarterectomy and infrarenal abdominal aortic aneurysm repair was performed, and local hospital administrative data were compared with Swedvasc registry data. External validation compared the numbers of cases in these two systems of data collection and internal validation compared data accuracy and completeness within individual patient records.
Hospital records identified 335 carotid and 393 abdominal aortic aneurysm (AAA) procedures, whereas Swedvasc identified 331 carotid and 359 AAAs. Nine carotid procedures and 64 AAA procedures were found in hospital administrative data but not in Swedvasc, and 14 carotids and 30 AAAs were found in Swedvasc but not in hospital data. External validity was 100% (95% CI 98.8-100%) for carotids and 98.8% (95% CI 96.9-99.5%) for AAAs. In internal validation, 0.8% of variables were missing in hospital data compared with Swedvasc and 4.2% were missing in Swedvasc compared with hospital data. Data contained within the data fields of Swedvasc and hospital data were the same in 97.4% (95% CI 96.3-98.3%) for carotids and 96.2% (CI 94.9-97.2%) for AAAs.
This study has provided a template for international validation of registry data and has demonstrated that Swedvasc is a highly accurate system of data collection for Swedish vascular surgery.
Two large randomized trials showed that elective endovascular aneurysm repair (EVAR) had similar all-cause long-term mortality rates but increased costs compared with open repair for nonruptured abdominal aortic aneurysms (AAAs). Despite these data, the use of EVAR continues to increase in North America. Currently, there are very limited adjusted population-based data examining long-term outcomes and resource utilization.
All patients who underwent elective AAA repair between April 2002 and March 2007 in Ontario were identified using data from hospital discharge abstracts. Patients were identified with a validated algorithm. A propensity score analysis was used to adjust for treatment allocation. Clinical outcomes included time to all-cause death and discharge to a nursing home or long-term care facility. Resource utilization outcomes included imaging utilization, hospital utilization, and reintervention rates.
Overall, 6461 patients underwent treatment of nonruptured AAAs, comprising 888 EVARs and 5573 open repairs. EVAR patients were older and had more comorbidities. The adjusted mortality was significantly lower in the EVAR group at 30 days (adjusted odds ratio [adj-OR], 0.34; 95% confidence interval [95% CI], 0.20-0.59), but long-term mortality was similar (adj-OR, 0.95; 95% CI, 0.81-1.05). EVAR patients were significantly less likely to be discharged to a nursing home or other chronic care facility (adj-OR, 0.55; 95% CI, 0.41-0.74). Imaging utilization as well as urgent and vascular readmissions were significantly higher in the EVAR group. However, the EVAR group had a significantly shorter length of stay and less intensive care unit use for the index hospitalization and decreased hospital length of stay during follow-up. There was a trend toward a slightly increased risk of reintervention with EVAR (adj-OR, 1.3; 95% CI, 0.98-1.75).
Compared with open repair, EVAR significantly reduced short-term but not long-term mortality. The EVAR patients spent less time in health institutions, including long-term care facilities, but underwent more imaging studies. Future improvements in EVAR could result in further decreases in reinterventions and subsequent radiologic monitoring.
Screening for abdominal aortic aneurysms (AAAs) substantially reduces aneurysm-related mortality in men and is increasing worldwide. This cohort study compares post-operative mortality and complications in men with screening-detected vs. non-screening-detected AAAs.
Data were extracted from the Swedish National Registry for Vascular Surgery (Swedvasc) for all screening-detected men treated for AAA (n = 350) and age-matched controls treated for non-screening-detected AAA (n = 350).
There were no differences in baseline characteristics besides age, which was lower in the screening-detected group than in the non-screening-detected group (median 66 vs. 68, p
Endovascular abdominal aortic repair requires an adequate sealing zone. The chimney graft (CG) technique may be the only option for urgent high-risk patients who are unfit for open repair and have no adequate sealing zone. This single-center experience provides long-term results of CGs with endovascular repair for urgent and complex aortic lesions.
Between July 2006 and October 2012, 51 patients (16 women) with a median age of 77 years (interquartile range, 72-81 years), were treated urgently (within 24 hours [61%]) or semiurgently (within 3 days [39%]) with endovascular aortic repair and visceral CGs (n = 73). Median follow-up was 2.3 years (interquartile range, 0.8-5.0 years) for the whole cohort, 3 years for 30-day survivors, and 4.8 years for patients who are still alive.
Five patients (10%) died within 30 days. All of them had a sacrificed kidney. All-cause mortality was 57% (n = 29), but the chimney- and procedure-related mortality was 6% (n = 3) and 16% (n = 8), respectively. Chimney-related death was due to bleeding, infection, renal failure, and multiple organ failure. There were two postoperative ruptures; both were fatal although not related to the treated disease. The primary and secondary long-term CG patencies were 89% (65 of 73) and 93% (68 of 73), respectively. Primary type I endoleak (EL-I) occurred in 10% (5 of 51) of the patients, and only one patient had recurrent EL-I (2%; 1 of 51). No secondary endoleak was observed. Chimney-related reintervention was required in 16% (8 of 51) of the patients because of EL-I (n = 3), visceral ischemia (n = 4), and bleeding (n = 2). The reinterventions included stenting (n = 5), embolization (n = 3), and laparotomy (n = 2). Thirty-one visceral branches were sacrificed (9 celiac trunks, 9 right, and 13 left renal arteries). Among the 30-day survivors, 8 of 17 patients (47%) with a sacrificed kidney required permanent dialysis; of these, seven underwent an urgent index operation. The aneurysm sac shrank in 63% (29 of 46) of cases.
The 6% chimney-related mortality and 93% long-term patency seem promising in urgent, complex aortic lesions of a high-risk population and may justify a continued yet restrictive applicability of this technique. Most endoleaks could be sealed endovascularly. However, sacrifice of a kidney in this elderly cohort was associated with permanent dialysis in 47% of patients.