In the event of rupture of an abdominal aortic aneurysm (AAA), mortality is very high. AAA prevalence and incidence of ruptures have been reported to be decreasing. The treatment of AAA has also undergone a change in recent decades with a shift toward endovascular aneurysm repair (EVAR). Our aim was to evaluate how these changes have affected the elective and emergency treatment of AAA and their results in Finland.
All patients treated for AAA in Finland, a country with a population of 5.5 million, during 2000 to 2014 were searched from the registry of the Finnish Institute for Health and Welfare. Data on all patients who had died of AAA during the same time period were obtained from Statistics Finland. The data were combined and analyzed.
The annual incidence of ruptured AAA was 16.4 per 100 000 population over 50 years and decreased significantly during the study period. Over half of the 4949 patients who had a ruptured AAA died outside the hospital. Thirty-day mortality after emergency repair was 39.4%. Intact AAA repairs numbered 4956. The absolute number of annual repairs increased during the study period, and the use of EVAR became the dominant method of elective repair. Thirty-day mortality in elective AAA repair dropped significantly from 6.3% in 2000 to 2004 to 2.7% in 2010 to 2014 mostly because of the increased number of EVAR procedures with lower mortality. Long-term mortality in patients treated with EVAR was higher than in patients treated with open repair. Mortality after elective AAA repair was primarily attributable to cardiovascular causes, but there was a slightly higher proportion of AAA-related late deaths in patients treated with EVAR.
Ruptured AAA incidence for men >65 years has declined by nearly 30% in Finland, likely because of the decrease in AAA prevalence. The treatment results have improved as well for both elective and emergency repair. Increased use of EVAR has resulted in a decrease of mortality after elective AAA repair, but results of open repair have improved as well. However, late mortality from elective EVAR is surprisingly high in comparison with open repair, which may have been exaggerated by patient selection.
Ruptured abdominal aortic aneurysms (AAA) cause 600 deaths per year in Sweden. As most patients are without symptoms prior to rupture, and about half the patients with a ruptured AAA die before arrival to hospital, the only way to reduce mortality substantially would be by screening and prophylactic treatment. The article reviews experience of screening for AAA from other European countries, data from the Swedish vascular registry (Swedvasc) and from the official registry of the causes of death in Sweden. With these data as input, a theoretical model of inviting all 65-year-old men in Sweden to take part in a screening programme for AAA is created. When the programme is fully developed after ten years, assuming an attendance rate of 75%, mortality in AAA would decrease from 630 to 346 per year. The total cost would increase from 154 to 161 million SEK (9 SEK = 1 Euro). The reason for the relatively minor increase in cost is explained by the fact that expensive emergency operations for ruptured AAA decrease by 50%. The cost per life saved would be 3,000-4,000 SEK. In conclusion, available data suggest that screening for AAA in Sweden would save many lives at a low cost.
Comment In: Lakartidningen. 2003 May 22;100(21):1874-612815871
The objective of the study was to compare emergency operations for ruptured abdominal aortic aneurysm (RAAA) by a mobile operation team, with operation for RAAA carried out at our vascular unit. During a five year period (1993-1998), 18 emergency operations were carried out for abdominal aortic aneurysm (AAA) with rupture at the primary receiving hospital with assistance from a mobile operation team. In the same period 82 aneurysms with rupture were resected at our vascular surgical unit. Preoperatively, patients operated at the primary receiving hospitals had significantly lower blood pressure (P
BACKGROUND: The management of infrarenal aortic aneurysms in high-risk patients remains a challenge. Endovascular aneurysm repair (EVAR) is associated with superior short-term mortality rates but unclear long-term results and has not been shown to improve survival in patients unfit for open repair (OR). The aim of this population-based study was to evaluate the outcome after elective EVAR compared with OR in a high-risk patient cohort. METHODS: Prospectively collected data from January 2000 to December 2006 were retrieved from the Swedish Vascular Registry. The high-risk cohort was defined as age >or=60 years, American Anesthesiologists Association (ASA) class 3 or 4, and at least one cardiac, pulmonary, or renal comorbidity. These criteria were met by 217 of 1000 EVAR patients and 483 of 2831 OR patients. Primary end points were 30-day and 1-year all-cause mortality. Kaplan-Meier curves for survival and multivariate Cox regression analyses were performed. RESULTS: The crude 30-day and 1-year all-cause mortality rates for EVAR vs OR for the whole treatment group (n = 3831) were 1.8% vs 2.8% and 8.0% vs 7.2%, respectively. In the high-risk cohort (n = 700), EVAR patients were approximately 2 years older and renal insufficiency and diabetes mellitus were more common, and smoking was more prevalent in the OR group. About two-thirds of EVAR procedures were performed at university hospitals and one-half of OR procedures were performed at county hospitals. In the high-risk cohort, there was no difference in mortality at 30-days (EVAR, 4.6% vs OR, 3.3%), but OR had lower 1-year mortality (8.5% vs 15.9%; P = .003). More bleeding complications occurred in the EVAR group, but more pulmonary complications occurred in the OR group; however, there was no difference in cardiac, cerebrovascular, or renal complications. The mean follow-up was 3.4 years. EVAR was associated with increased mortality risk after adjusting for age, ASA class, and comorbidities (hazard ratio, 1.50; 95% confidence interval, 1.07-2.12; P = .02). Kaplan-Meier survival analysis showed a lower mortality rate for patients undergoing OR, which remained during follow-up (P = .001). CONCLUSIONS: Elective OR of aortic aneurysms seems to have a better outcome compared with EVAR in this specific, population-based, high-risk patient cohort after adjusting for covariates. We cannot confirm the benefit of EVAR from previous registry studies with a similar high-risk definition. In clinical practice, OR may be at least as good as EVAR in high-risk patients fit for surgery.
Is there a difference in the population-based survival rate for patients with ruptured abdominal aortic aneurysms (rAAA), handled by a "one-stop" or a "two-stop" referral pattern?
Ten regions in Sweden were identified where clear-cut "one-stop" or "two-stop" referral-patterns prevailed. From the Swedvasc Registry we identified 849 patients operated on for rAAA, 1987 to 2004, living in any of these ten regions, and related the number of survivors to the whole population served by each hospital.
The population-based survival rate was 14% lower for patients following a "two-stop" compared to a "one-stop" referral pattern (P=0.084). For the group 65-74 years-of-age the difference was significant (P=0.021), but no corresponding effect was seen regarding operative mortality rate or sex.
Compared to a "one-stop" referral pattern for rAAA, a "two-stop" referral pattern results in a lower population-based survival rate for patients 65-74 years old, but the consequences would be small even if a "one-stop" referral pattern could be generally accomplished.
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
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
The purpose of this study was to examine the changing trends in surgical management of patients with abdominal aortic aneurysms at a tertiary care teaching hospital over the past 40 years, by analysis of demographic data, perioperative variables and outcomes on all patients having abdominal aortic aneurysm surgery between 1955 and 1993. Some 1604 abdominal aortic aneurysms were assessed. The annual rate of abdominal aortic aneurysm surgery increased from 17.6 to 67.8 cases per year. The non-ruptured to ruptured abdominal aortic aneurysm ratio increased from 2.4:1 in the first decade to 3.4:1 in the last 5 years. In non-ruptured abdominal aortic aneurysm repairs, the following variables changed over the four decades: patients age over 80 years increased (2.4% to 8.0%; P
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.