Article

Regarding "Effect of gender on long-term survival after abdominal aortic aneurysm repair based on results from the Medicare national database" Reply

Department of Health Evidence and Policy, Mount Sinai School of Medicine, New York, NY, USA.
Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter (Impact Factor: 3.02). 04/2011; 54(1):1-12.e6; discussion 11-2. DOI: 10.1016/j.jvs.2010.12.049
Source: PubMed

ABSTRACT

Historically, women have higher procedurally related mortality rates than men for abdominal aortic aneurysm (AAA) repair. Although endovascular aneurysm repair (EVAR) has improved these rates for men and women, effects of gender on long-term survival with different types of AAA repair, such as EVAR vs open aneurysm repair (OAR), need further investigation. To address this issue, we analyzed survival in matched cohorts who received EVAR or OAR for both elective (eAAA) and ruptured AAA (rAAA).
Using the Medicare Beneficiary Database (1995-2006), we compiled a cohort of patients who underwent OAR or EVAR for eAAA (n = 322,892) or rAAA (n = 48,865). Men and women were matched by propensity scores, accounting for baseline demographics, comorbid conditions, treating institution, and surgeon experience. Frailty models were used to compare long-term survival of the matched groups.
Perioperative mortality for eAAAs was significantly lower among EVAR vs OAR recipients for both men (1.84% vs 4.80%) and women (3.19% vs 6.37%, P < .0001). One difference, however, was that the survival benefit of EVAR was sustained for the 6 years of follow-up in women but disappeared in 2 years in men. Similarly, the survival benefit of men vs women after elective EVAR disappeared after 1.5 to 2 years. For rAAAs, 30-day mortality was significantly lower for EVAR recipients compared with OAR recipients, for both men (33.43% vs 43.70% P < .0001) and women (41.01% vs 48.28%, P = .0201). Six-year survival was significantly higher for men who received EVAR vs those who received OAR (P = .001). However, the survival benefit for women who received EVAR compared with OAR disappeared in 6 months. Survival was also substantially higher for men than women after emergent EVAR (P = .0007).
Gender disparity is evident from long-term outcomes after AAA repair. In the case for rAAA, where the long-term outcome for women was significantly worse than for men, the less invasive EVAR treatment did not appear to benefit women to the same extent that it did for men. Although the long-term outcome after open repair for elective AAA was also worse for women, EVAR benefit for women was sustained longer than for men. These associations require further study to isolate specific risk factors that would be potential targets for improving AAA management.

Download full-text

Full-text

Available from: Alan J Moskowitz, Feb 26, 2014
  • Source

    Preview · Article · Nov 2011 · Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: The risks of myocardial infarction (MI) and stroke after abdominal aortic aneurysm (AAA) resection are not known. Prophylaxis with aspirin and statins is not generally recommended, although patients with AAAs have an increased prevalence of cardiovascular atherosclerosis. We report the incidences of MI, stroke, and death in an unselected national cohort of patients operated on for AAAs, with the general population as the control group. In a matched cohort study, 11,094 Danish patients who underwent acute or elective open AAA repair from January 1986 through June 2009 were compared with four randomly chosen age- and sex-matched individuals (controls) from the general population (n = 44,364). Data were collected retrospectively from the Danish Vascular Registry (Karbase), the National Population Registry, and the National Inpatient Registry. The groups were analyzed for the incidences of MI, stroke, and death, with up to 20 years of follow-up. AAA patients had an annual MI incidence of 2.5% (hazard ratio, 2.1; 95% confidence interval [CI], 1.9-2.2) compared with the general population. The annual incidence of stroke was 2.9% (hazard ratio, 1.8; 95% CI, 1.6-1.9), and there was a 2.4-fold (95% CI, 2.3-2.4) increase in the hazard of all-cause mortality compared with the general population. AAA patients of both sexes have a high risk of atherosclerotic events (MI, stroke) and death, so lifelong prophylaxis must be considered from our epidemiologic data. Randomized trials investigating the potential benefit of aspirin and statin therapy in AAA patients are needed.
    Preview · Article · Nov 2011 · Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: The use of fenestrated and branched stent graft technology for paravisceral abdominal aortic aneurysms (PAAA) is on the rise; however, its application is limited in the United States to only a few selected centers. Most PAAAs are currently repaired using an open approach. The objective of this study was to determine which patients are at highest risk with open PAAA repair and might benefit most from endovascular repair using fenestrated or branched stent grafts. This was a retrospective cohort study using data from American College of Surgeons National Surgical Quality Improvement Program (NSQIP) hospitals. We identified 598 patients (27.5% women) who underwent elective open PAAA repair from the 2007 to 2009 NSQIP, a prospective database maintained at >250 centers. The main outcome measure was 30-day postoperative mortality. The median patient age was 73 years. The 30-day major morbidity rate was 30.1%, and the mortality rate was 4.5%. Major complications included reintubation (10.0%), sepsis (10.7%), return to operating room (9.2%), new dialysis requirement (5.9%), cardiac arrest or myocardial infarction (4.5%), and stroke (1.2%). Multivariate analyses identified four predictors of postoperative mortality after open PAAA repair: peripheral arterial disease (PAD) requiring revascularization or amputation, chronic obstructive pulmonary disease (COPD), anesthesia time, and female sex. PAD and COPD were present in only 5.2% and 20.4% of patients but were associated with a 16.1% and 9.0% mortality rate, respectively. The mortality rate in women was 7.3% vs 3.5% for men (P = .045). PAD, COPD, and female sex are major risk factors for postoperative mortality after open PAAA repair. Fenestrated or branched stent graft repair may be a more valuable alternative to open repair for patients with one or more of these characteristics who have suitable access vessels.
    Full-text · Article · Dec 2011 · Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Show more