Population-Based Outcomes Following Endovascular and Open Repair of Ruptured Abdominal Aortic Aneurysms

Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.
Journal of Endovascular Therapy (Impact Factor: 3.35). 10/2009; 16(5):554-64. DOI: 10.1583/09-2743.1
Source: PubMed

ABSTRACT To evaluate national outcomes after endovascular and open surgical repair of ruptured abdominal aortic aneurysms (rAAA).
The Nationwide Inpatient Sample was interrogated to identify all repairs between 2000 and 2005 for rAAA based on ICD-9 codes. In the study period, 2323 patients (1794 men; median age 75 years, range 45-98) with rAAAs had endovascular repair, while 26,106 patients (20,311 men; median age 73 years, range 22-99) had an open procedure. Outcomes included in-hospital mortality, length of stay (LOS), complications, and hospitalization charge. A secondary analysis was performed to compare outcomes from low-, medium-, and high-volume institutions based on annual rAAA repair volume.
Patients in the endovascular group were significantly older (p<0.05). Mortality was 41% overall: 33% and 41% for endovascular versus open repair, respectively (p<0.001). Mortality after endovascular repair was lower than open surgery for patients >or=70 years (36% versus 47%, p<0.001), but not for those <70 years (24% versus 30%, p = 0.15). LOS was shorter after endovascular repair (7 versus 9 days, p<0.001). Respiratory complications (8% versus 4%, p<0.05) and acute renal failure were more common following open repair (30% versus 23%, p<0.01). Costs were similar (endo $73,590 versus open $67,287, p = 0.15). Mortality decreased as hospital surgical volume increased (low 44%, medium 39%, high 38%; p<0.001). Over time, endovascular repair utilization increased more rapidly at high-volume centers, and a lower mortality was seen with endovascular repair at high-volume compared to low-volume hospitals (22% versus 44%, p<0.001). Multivariate predictors of mortality were age, female gender, lower hospital surgical volume, open repair, and year of surgery.
This population-based study found that mortality associated with rAAAs may be improved by the performance of endovascular repair, especially in older patients. Mortality after rAAA for both endovascular and open repairs was also lower at high-volume institutions.

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    • "Centers performing EVAR for rAAA whenever possible, did so in 28% to 79% of their patients, and had a 30-day mortality of 19.7% for 680 EVAR patients and 36.3 % for 763 open repair patients. In addition, outcome following endovascular and open repair of rAAA was evaluated by Giles et al., 2009 interrogating the Nationwide Inpatient Sample database to identify all repairs between 2000 and 2005 for rAAA. In the study period, 2323 patients (1794 men; median age 75 years) with rAAA had endovascular repair, while 26,106 patients (20,311 men; median age 73 years) had an open procedure. "
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    ABSTRACT: This review comments on prognosis and treatment of abdominal aortic aneurysm (AAA) with respect to rupture prevention by screening. The data demonstrate that a postoperative mortality rate of 1-3% has to be expected with endovascular aneurysm repair (EVAR) compared to 3-5% with open repair (OR), depending on the kind of study and patient risk factors. However, the slightly lower short-term rates of death with EVAR do not give enough evidence so far to change the recommendation that patients with asymptomatic AAA measuring not till £5.5 cm should undergo repair to eliminate the risk of rupture. Whether the introduction of EVAR has reduced the annual number of ruptured AAA is investigated at the moment. In-hospital operative mortality of ruptured AAA remains high and ranges between 30% to 50%, depending on patient selection and kind of rupture (free or covered perforation). Long-term follow-up of patients with repaired AAA demonstrates an unfavorable prognosis of these patients compared to the general population with the corresponding age. There is good evidence that screening for AAA in men aged 65 to 75 years who have ever smoked leads to a decreased AAA-specific mortality with a defensible cost-effectiveness. Nevertheless, mass screening for AAA is controversial since screening may have only small contributions to population mortality. The cost-effectiveness of screening may be substantially reduced if the indication for operation would be gradually expanded, increasing the case load of repaired AAA with smaller diameters (£5.5 cm). The psychological effects of screening on patients with smaller AAA left with the knowledge that they have a potentially life threatening condition that needs no treatment at the moment, are unknown. It is suggested that ultrasound examination of the abdomen by the general practitioner during routine check up would also increase the number of incidental detection of AAA in the selected risk group, without the serious psychological consequences of mass screening.
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