Failure to rescue trends in elective abdominal aortic aneurysm repair between 1995 and 2011.

Factors affecting mortality after abdominal aortic aneurysm (AAA) repair have been extensively studied, but little is known about the effects of the shift to endovascular aneurysm repair (EVAR) vs open repair on failure to rescue (FTR). This study examines the impact of treatment modalities on FTR for elective AAA surgery during the years 1995 to 2011. Data for 491,779 patients undergoing elective AAA surgery were collected from Medicare files. Patient demographics, comorbidities, hospital volume, and repair type were collected. Primary outcome was FTR: the percentage of deaths in patients who had a complication within 30 days of surgery. Data were analyzed by univariate and multivariate analysis. Patients undergoing AAA surgery have become progressively more complex, with 84.96%, 89.33%, 93.76%, and 95.72% presenting with one or more comorbidities in 1995, 2000, 2005, and 2011, respectively. Despite this, overall FTR after AAA surgery was stable from 1995 to 2000 (P = .38) and decreased from 2.68% to 1.58% between 2000 and 2011 (P < .001). In addition, FTR in EVAR decreased from 1.70% to 0.58% from 2000 to 2006 (P = .03) and then stabilized at 0.88% ± 0.9% after 2007 (P = .45). Unlike for EVAR, FTR for open repair remained stable at 3.06% ± 0.17% to 2.74% ± 0.16% from 1995 to 2000 (P = .38) but increased to 4.51% ± 0.21% in 2011 (P < .001). Mortality was highest after transfusion (20.86%), prolonged ventilation (17.37%), and respiratory complications (29.78%) for all AAA surgeries. Of note, high-volume hospitals had lower FTR rates than low-volume hospitals for both open (2.73% vs 5.66%; P < .001) and endovascular (0.7% vs 1.69%; P < .001) repair. Multivariate analysis showed that high annual volume hospital status (odds ratio, 0.6; confidence interval, 0.58-0.63) and endovascular repair (odds ratio, 0.3; confidence interval, 0.28-0.31) were associated with decreased FTR. The success in AAA surgery of rescuing patients from 30-day mortality after a complication is associated with increased volume of EVAR. This increased success can also be attributed to the improved FTR outcomes and complication rates when surgeries are performed at high-volume hospital centers.

Ilonzo N ，Egorova NN ，McKinsey JF ，Nowygrod R ... -  《-》

Interhospital transfer for intact abdominal aortic aneurysm repair.

Medically complex patients who need abdominal aortic aneurysm (AAA) repair are at increased risk of mortality. We study the effects of interhospital transfer to high-volume hospitals (HVHs) on postoperative complications and mortality after complications in these patients. Data for 491,779 patients undergoing intact AAA surgery were extracted using Medicare files. Patient demographics, comorbidities, hospital volume, repair type, and patient transfer status were collected. Primary outcomes were postoperative complications and failure to rescue within 30 days after surgery. Data were analyzed using multivariable and propensity analysis. From 2000 to 2011, the percentage of patients transferred to another hospital for surgery before starting treatment more than doubled from .7% to 1.9% for endovascular aneurysm repair (EVAR; P < .001) and from 1.2% to 3.7% for open repair (P < .001). At baseline, transferred patients had more congestive heart failure (18.7% vs 11.2%; P < .001), coronary (17.4% vs 15.0%; P < .001), pulmonary (38.3% vs 33.6%; P < .001), and renal failure (8.1% vs 4.6%; P < .001) comorbidities. Transferred patients incurred more complications after EVAR (25.1% vs 12.8%; P < .001) or open repair (42.3% vs 35.5%; P < .001). After propensity matching for comorbidities and demographics, there were fewer complication rates (40.4% vs 47.8%; P < .001) and decreased failure to rescue (5.5% vs 6.5%; P = .04) after open repair in patients transferred to HVHs than in patients who remained at the primary, low-volume hospital for surgery. Complication rates after EVAR for nontransferred patients at low-volume hospitals and transferred patients at HVHs were similar (23.9% vs 24.7%; P = .55). After propensity matching, there was no significant difference in failure to rescue (P = .06) after EVAR between patients transferred to HVHs and nontransferred patients who had procedures at low-volume hospitals. Transfer of medically complex patients to HVHs for open AAA repair improves outcomes in AAA surgery. Complication rates decrease, and survival of transferred patients increases when they undergo open repair at HVHs.

Ilonzo N ，Egorova NN ，Nowygrod R 《-》

Frailty increases the risk of 30-day mortality, morbidity, and failure to rescue after elective abdominal aortic aneurysm repair independent of age and comorbidities.

Frailty, defined as a biologic syndrome of decreased reserve and resistance to stressors, has been linked to adverse outcomes after surgery. We evaluated the effect of frailty on 30-day mortality, morbidity, and failure to rescue (FTR) in patients undergoing elective abdominal aortic aneurysm (AAA) repair. Patients undergoing elective endovascular AAA repair (EVAR) or open AAA repair (OAR) were identified in the National Surgical Quality Improvement Program database for the years 2005 to 2012. Frailty was assessed using the modified frailty index (mFI) derived from the Canadian Study of Health and Aging (CSHA). The primary outcome was 30-day mortality, and secondary outcomes included 30-day morbidity and FTR. The effect of frailty on outcomes was assessed by multivariate regression analysis, adjusted for age, American Society of Anesthesiology (ASA) class, and significant comorbidities. Of 23,207 patients, 339 (1.5% overall; 1.0% EVAR and 3.0% OAR) died ≤30 days of repair. One or more complications occurred in 2567 patients (11.2% overall; 7.8% EVAR and 22.1% OAR). Odds ratios (ORs) for mortality adjusted for age, ASA class, and other comorbidities in the group with the highest frailty score were 1.9 (95% confidence interval [CI], 1.2-3.0) after EVAR and 2.3 (95% CI, 1.4-3.7) after OAR. Similarly, compared with the least frail, the most frail patients were significantly more likely to experience severe (Clavien-Dindo class IV) complications after EVAR (OR, 1.7; 95% CI, 1.3-2.1) and OAR (OR, 1.8; 95%, CI, 1.5-2.1). There was also a higher FTR rate among frail patients, with 1.7-fold higher risk odds of mortality (95% CI, 1.2-2.5) in the highest tertile of frailty compared with the lowest when postoperative complications occurred. Higher mFI, independent of other risk factors, is associated with higher mortality and morbidity in patients undergoing elective EVAR and OAR. The mortality in frail patients is further driven by FTR from postoperative complications. Preoperative recognition of frailty may serve as a useful adjunct for risk assessment.

Arya S ，Kim SI ，Duwayri Y ，Brewster LP ，Veeraswamy R ，Salam A ，Dodson TF ... -  《-》

The effect of hospital factors on mortality rates after abdominal aortic aneurysm repair.

Patient factors that contribute to mortality from abdominal aortic aneurysm (AAA) repair have been previously described, but few studies have delineated the hospital factors that may be associated with an increase in patient mortality after AAA. This study used a large national database to identify hospital factors that affect mortality rates after open repair (OAR) and endovascular AAA repair (EVAR) of elective and ruptured AAA. A retrospective analysis was completed using the Nationwide Inpatient Sample from 1998 to 2011. International Classification of Disease, Ninth Revision codes were used to identify patients who underwent elective or ruptured AAA repair by OAR or EVAR. The association between mortality and hospital covariates, including ownership, bed size, region, and individual hospital volume for these patients was statistically delineated by analysis of variance, χ(2), and Mann-Kendall trend analysis. A total of 128,232 patients were identified over the 14-year period, of which 88.5% were elective procedures and 11.5% were performed acutely for rupture. Most hospitals that complete elective OAR do between one and 50 cases, with mortality between 0% and 40%. Hospitals with mortality >40% uniformly complete fewer than five elective OAR cases annually and fall in the bottom 2.5% of all hospitals for mortality. Most hospitals that complete elective EVAR do between one and 70 cases, with mortality between 0% and 13%. Hospitals with mortality >13% uniformly complete fewer than eight elective EVAR cases annually and fall in the bottom 2.5% of all hospitals for mortality. The majority of hospitals that complete OAR or EVAR for ruptured AAA have between 0% to 100% for mortality, indicative of the high mortality risk associated with rupture. Hospitals that complete fewer than five OARs or eight EVARs annually have significantly greater mortality compared with their counterparts. Improved implementation of best practices, more detailed informed consent to include hospital mortality data, and better regional access to health care may improve survival after elective AAA repair.

Dua A ，Furlough CL ，Ray H ，Sharma S ，Upchurch GR ，Desai SS ... -  《-》

Mortality variability after endovascular versus open abdominal aortic aneurysm repair in a large tertiary vascular center using a Medicare-derived risk prediction model.

Previous reports have documented better outcomes after open abdominal aortic aneurysm (AAA) repair in tertiary centers compared with lower-volume hospitals, but outcome variability for endovascular AAA repair (EVAR) vs open AAA repairs in a large tertiary center using a Medicare-derived mortality risk prediction model has not been previously reported. In the current study, we compared the observed vs predicted mortality after EVAR and open AAA repair in a single large tertiary vascular center. We retrospectively analyzed all patients who underwent repair of a nonruptured infrarenal AAA in our center from 2003 to 2012. Univariable and multivariable logistic regression were used to evaluate 30-day mortality. Patients were stratified into low-risk, medium-risk, and high-risk groups, and mortality was predicted for each patient based on demographics and comorbidities according to the Medicare risk prediction model. We analyzed 297 patients (EVAR, 72%; open AAA repair, 28%; symptomatic, 25%). Most of our patients were of high and moderate risk (48% and 28%, respectively). The observed 30-day mortality was 1.9% after EVAR vs 2.4% after open repair (odds ratio [OR], 0.77; 95% confidence interval [CI], 0.14-4.29; P = .67). There was no difference in mortality with EVAR vs open repair after adjusting for predefined patient characteristics (OR, 0.92; 95% CI, 0.16-7.43; P = .93); only preoperative renal disease was predictive of 30-day mortality after AAA repair in our cohort (OR, 8.39; 95% CI, 1.41-67.0). The observed mortality within our study was significantly lower than the Medicare-derived expected mortality for each treatment group within patients stratified as high risk or medium risk (P ≤ .0002 for all). Despite treating patients with high preoperative risk status, we report a 10-fold decrease in operative mortality for EVAR and open AAA repair in a tertiary vascular center compared with national Medicare-derived predictions. High-risk patients should be considered for aneurysm management in dedicated aortic centers, regardless of approach.

Hicks CW ，Black JH 3rd ，Arhuidese I ，Asanova L ，Qazi U ，Perler BA ，Freischlag JA ，Malas MB ... -  《-》