Gender and 30-day outcome in patients undergoing endovascular aneurysm repair (EVAR): an analysis using the ACS NSQIP dataset.

Abedi NN ，Davenport DL ，Xenos E ，Sorial E ，Minion DJ ，Endean ED ... -  《-》

Variations in early outcomes of endovascular aneurysm repair with alternate endograft configurations.

Most endovascular abdomincal aortic aneurysm (AAA) repairs (EVARs) performed in the United States utilize a bifurcated configuration. The purpose of this study was to examine the effect of alternate graft configurations on early outcomes during EVAR. Patients in the National Surgical Quality Improvement Program (NSQIP) participant use file who underwent elective EVAR for AAA from 2005 to 2007 were stratified by configuration using CPT codes. Bifurcated configurations (CPT 34802, 34803, 34804) were compared to straight configurations such as tube or aortouni-iliac grafts (CPT 34800, 34805). Preoperative risk factors, intraoperative variables, 30-day outcome measures, and length of stay were compared. Composite morbidity included patients experiencing one or more of 21 complications defined by NSQIP protocol. Student's t-test and analyses of variance were used to compare variables. There were 3,264 patients who underwent EVAR, including 2,864 bifurcated endografts and 400 straight endografts. Composite morbidity was greater in patients receiving straight endografts compared to those receiving bifurcated endografts (15.2% vs. 9.3%, p < 0.001). Length of stay was greater in the "straight" cohort as well (4.9 + or - 6.9 vs. 3.3 + or - 5.6, p < 0.001). There was a trend toward increased mortality in the "straight" cohort, but it did not reach statistical significance (2% vs. 0.9%, p = 0.054). After controlling for the top 11 NSQIP predictors of mortality in vascular patients, graft configuration remained significant in the multivariable analysis for morbidity (odds ratio [OR] = 1.55, 95% confidence interval [CI[ 1.13-2.12, p = 0.006) and length of stay but not mortality (OR = 1.63, 95% CI 0.70-3.80, p = 0.263). EVAR using a tube or aortouni configuration is associated with increased complications and length of stay. These poorer outcomes may be related to factors that lead surgeons to choose these approaches.

O'Keeffe SD ，Davenport D ，Endean ED ，Xenos ES ，Sorial EE ，Minion DJ ... -  《-》

Comparable mortality with open repair of complex and infrarenal aortic aneurysm.

A consequence of endovascular aneurysm repair (EVAR) of anatomically straightforward infrarenal abdominal aortic aneurysm repair cohort (AAA) is that open aneurysm repair is more commonly performed for complex anatomy. Complex aneurysm repair with visceral vessel involvement (CAA) or combined aneurysm repair and visceral vessel reconstruction (VVR) has traditionally been considered to increase morbidity and mortality compared with repair of infrarenal AAA. This study evaluated contemporary outcomes of open abdominal aneurysm surgery, including AAA, CAA, and VVR using the National Surgical Quality Improvement Program (NSQIP) database. The NSQIP Participant Use File was queried by CPT code to identify patients undergoing AAA, CAA, and VVR (2005-2008). Comparative analysis of clinical features, technical details and 30-day outcomes was performed using univariate methods. Logistic regression analysis was used to identify predictors of morbidity and mortality. A total of 2820 patients underwent AAA and 592 CAA. Renal insufficiency (ie, creatinine >1.4 mg/dL) rates were similar in AAA and CAA patients, however, more frequent in patients with VVR (51% vs 31% [no bypass]; P < .01). CAA was less likely to be performed urgently (6.3% vs 9.1%; P < .05) and was associated with increased operative time (254 ± 100 vs 224 ± 93; P < .01) compared with AAA. Univariate analysis showed that CAA did not increase mortality (5.7% vs 5.1%; P = .5). CAA slightly increased overall complications (32% vs 27%; P = .01) compared with AAA. 73 (2.5%) AAA and 84 (12%) CAA patients had simultaneous VVR and these patients exhibited a trend toward increased mortality (8.9% vs 5.2%; P = .07). VVR increased complications (43% (VVR) vs 26% [no bypass]; P < .01), including ventilation >48 hours (21% [VVR] vs 12% [no bypass]; P < .01), renal failure (7.6% [VVR] vs 4.1% [no bypass]; P = .04), and sepsis (13% [VVR] vs 6.3% ([no bypass]; P < .01). Multivariate analysis demonstrated that CAA (odds ratio [OR], 1.3 [95% confidence interval (CI), 1.1-1.6]; P = .01) and VVR (OR, 2.2 [95% CI, 1.8-3.6]; P < .01) increased the odds of any complication. Independent predictors of mortality included dependent functional status (OR, 3.6 [95% CI, 2.3-5.4]; P < .01), elevated pre-op creatinine (OR, 2.9 [95% CI, 2.2-4.0]; P < .01), type II diabetes (OR, 1.6 [95% CI, 1.05-2.4]; P = .03), and age (OR, 1.06 [95% CI, 1.03-1.08]; P < .01). Neither CAA (OR, 1.2 [95% CI, 0.84-1.8]; P = .3) nor VVR (OR, 1.6 [95% CI, 0.89-2.9]; P = .11) were associated with increased mortality compared with AAA. In contemporary practice the migration of open repair to increasingly complex cases has been achieved with 30-day mortality essentially equivalent to open repair of infrarenal AAA. Patients who require VVR do sustain increased complications, in particular renal failure. These data also emphasize the importance of baseline renal insufficiency in clinical decision making. CAA and VVR are associated with increased morbidity in comparison to AAA repair; however, both procedures can be safely performed in patients without increased risk of operative mortality.

Patel VI ，Lancaster RT ，Conrad MF ，Lamuraglia GM ，Kwolek CJ ，Brewster DC ，Cambria RP ... -  《-》

Women derive less benefit from elective endovascular aneurysm repair than men.

Women have a lower chance of surviving elective open abdominal aortic repair. The reasons for this are not clear. Endovascular repair has clearly reduced early and midterm morbidity and mortality for patients with large abdominal aortic aneurysms (AAAs). However, most patients are male. It is unclear whether there has been any reduction in elective morbidity for females or what the extent of that reduction has been. We prospectively analyzed outcomes for elective endovascular aneurysm repair (EVAR) in women at our center and compared results with those for elective open surgery and emergent open and endovascular repair. All patients undergoing elective and emergency AAA from 2002 to 2009 were prospectively entered into a database. Demographic details, including gender, were tabulated. Outcome measures were operative blood loss, incidence of type 1 endoleaks, length of in-hospital stay, postoperative complications, 30-day all-cause mortality, and secondary interventions during the follow-up period. Statistical analysis was performed using Fischer exact test and Student t test. A multivariate analysis was also performed. From 2002 to 2009, there were 2631 abdominal aortic aneurysms (AAA) open and endovascular repairs performed in our center (1698 endovascular aneurysm repairs [EVARs], 933 "open"). Males comprised 1995 (76%) of patients; females 636 (24%). There were 1592 elective EVARs (1248 male, 344 female) and 106 emergency EVARs (73 male, 33 female). Elective open repair was performed in 788 patients (579 male, 209 female) and emergency open repair in 149 (73 male, 76 female). For women, elective EVAR resulted in significantly greater mortality rates than men (3.2% vs 0.96%, P < .005). There was a greater incidence of intraoperative aortic neck or iliac artery rupture (4.1% vs 1.2% P = .002) and use of Palmaz stents for type 1 endoleaks (16.1% vs 8%, P = .0009). Mean blood loss was greater in females (327 mL vs 275 mL, P = .038). Perioperative complications were also more frequent in women: leg ischemia (3.5% vs 0.6%, P = .003) and colon ischemia requiring colectomy (0.9% vs 0.2%, P = .009). Mean hospital stay was also longer (3.7 days vs 2.2 days, P = .0001). In contrast, there were no gender differences for any of these outcome measures for elective open repair or emergency open surgery or EVAR. There was no significant difference in death rates between EVAR and open repair in women (3.2% vs 5.7%). In males, the 30-day mortality was 0.96% for elective EVAR and 4.7% for elective open surgery. Following logistic regression, female gender remains a significant risk even when the effects of aneurysm size and age are considered (odds ratio 3.4, P < .01). Mortality for females undergoing elective EVAR is significantly greater than for males. It is also more hazardous. Colon ischemia, native arterial rupture, and type 1 endoleaks are more frequent. Elective endovascular aneurysm repair benefits men more than women.

Mehta M ，Byrne WJ ，Robinson H ，Roddy SP ，Paty PS ，Kreienberg PB ，Feustel P ，Darling RC 3rd ... -  《-》

Thirty-day NSQIP database outcomes of open versus endoluminal repair of ruptured abdominal aortic aneurysms.

The mortality of ruptured abdominal aortic aneurysm (rAAA) has decreased 3.5% per decade in the last 50 years to a current rate of 40%-50%. Reports have indicated that endovascular repair (EVAR) is feasible for rAAA and may offer potential benefits over open repair. We examined the National Surgical Quality Improvement Program (NSQIP) database to compare 30-day multicenter outcomes for EVAR vs open rAAA repair. Patients that underwent rAAA repair in the NSQIP database from 2005 to 2007 were identified through a combination of Current Procedural Terminology (CPT) codes and International Classification of Diseases-Ninth Revision (ICD-9) diagnoses. Preoperative comorbidities, operative duration and transfusion, and 30 day outcomes were evaluated using t tests or Chi-squared tests depending on the variable. A separate multivariable regression was performed for each outcome adjusting for all independently predictive preoperative and intraoperative risk factors. A total of 427 patients were identified and 76.8% of patients underwent open repair. The open repair groups exhibited lower albumin levels and higher percentage of patients with preoperative hematocrit (Hct) <38% and need for preoperative ventilation. The requirement for preoperative blood transfusion was similar. Patients undergoing open repair had much higher intraoperative transfusion requirements (11.8 +/- 8.9 vs 4.2 +/- 6.0 red blood cell units, P < .001). After adjustment for preoperative mortality risk factors, the mortality risk was higher for open repair versus EVAR (odds ratio 1.67, 95% confidence interval [CI] 0.91-3.05, P = .096) but did not reach significance. After similar adjustment the composite morbidity odds ratio for open repair versus EVAR was 1.82 (95% CI 1.11-2.99, P = .018) and the pulmonary adverse events odds ratio was 1.99 (95% CI 1.22-3.25, P = .006). Risks for the other outcomes were not significant. Composite 30-day morbidity risk is lower after EVAR vs open repair of rAAA. Open repair is associated with increased transfusion requirements. Performance of EVAR in rAAA patients with favorable anatomy could potentially result in improved outcome as compared with open repair.

Davenport DL ，O'Keeffe SD ，Minion DJ ，Sorial EE ，Endean ED ，Xenos ES ... -  《-》