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Survival is not improved by elective repair of abdominal aortic aneurysms smaller than 5.5 cm, even when operative mortality is low.

UPTURE OF ABDOMINAL AORtic aneurysm (AAA) can be prevented by elective surgical repair, but because most AAA never rupture, 1 elective repair is reserved for patients at high risk of rupture. The most commonly used predictor of rupture is the maximum diameter of the AAA. Two randomized trials found no reduction in mortality from repairing AAA smaller than 5.5 cm in patients at low operative risk. 2,3 No randomized trials are available in patients with larger AAA, and decision making in these patients is often complicated by advanced age and serious comorbidities. Surgery is usually deferred in highoperative-risk patients until the AAA attains a diameter at which the risk of rupture is thought to outweigh the operative risk. However, few data are available on the rupture risk of large AAA, resulting in substantial disagreement among experts. 4 We conducted a prospective observational Veterans Affairs Cooperative Study to determine the incidence of rupture in patients with large AAA for whom elective repair was not planned because of medical contraindications or patient refusal. METHODSEligible patients were those evaluated at 47 Veterans Affairs medical centers who were diagnosed as having AAA of at least 5.5 cm in diameter by ultrasonography or computed tomography (CT) within 3 months prior to enrollment and for

Ultrasound-guided compression repair (UGCR) of catheterization-related femoral artery injuries was evaluated as a possible new imaging-guided interventional procedure. Thirty-nine femoral artery injuries (35 pseudoaneurysms, four arteriovenous fistulas) were detected with color Doppler flow imaging in patients with enlarging groin hematomas and/or groin bruits 6 hours to 14 days after catheterization procedures. UGCR was not performed in 10 patients due to spontaneous thrombosis (n = 4), infection (n = 1) or skin ischemia (n = 1), unsuitable anatomy (n = 3), or excessive discomfort (n = 1). The remaining 29 patients underwent a full trial of compression therapy, and the lesion was eliminated in 27. Follow-up color flow scans were obtained after 24-72 hours in all 27 successful cases and at 1-15 months in 19; no recurrences or complications occurred. UGCR for acute injuries is safe and technically simple and is promising as a cost-effective, first-line treatment for uncomplicated catheterization-related femoral artery injuries. UGCR is probably not appropriate for long-standing injuries.

Most venous ulcers can be expected to heal when patients are enrolled in a nurse-managed/physician-supervised ambulatory ulcer clinic. Photoplethysmography-derived venous refill time of 10 seconds or less predicted delayed healing. Strict compliance with the treatment protocol significantly decreased the time to healing and prolonged the time to recurrence.

Lederle FA, Freischlag JA, Kyriakides TC, and the OVER Veterans Affairs Cooperative Study Group. N Engl J Med 2012;367:1988-97. Conclusion:Endovascular and open repair of abdominal aortic aneurysm (AAA) have similar long-term survival. In those aged <70 years, survival tends to be better with endovascular repair, whereas in those aged >70 years, survival appears improved with open repair.Summary: With the exception of colectomy, aneurysm repair results in more perioperative deaths than any other general or vascular surgical procedure, w1250 perioperative deaths per year (Ghaferi AA et al, N Engl J Med 2009;1361-8-75). Randomized trials have demonstrated decreased perioperative mortality in patients undergoing endovascular AAA repair. This survival advantage in the United Kingdom EVAR 1 trial and the Dutch DREAM trial was lost #2 years due to excess late deaths in the endovascular repair groups (The United Kingdom EVAR Trial Investigators, N Engl J Med 2010;362:1863-71; De Bruin JL et al, N Engl J Med 2010;362:1881-9). In the Veterans Affair Cooperative Study of Open vs Endovascular Repair (OVER), excess late deaths in the endovascular groups were not noted at 2 years (Lederle FA et al, JAMA 2009;302:1535-42). The authors of this study present the longer-term results of the OVER trial. In the trial, 881 patients with asymptomatic AAAs who were candidates for open or endovascular repair were randomized to endovascular repair (n ¼ 444) or open repair (n ¼ 437). Followup is for up to 9 years (mean, 5.2 years). Forty-two Veteran's Affairs medical centers participated in the trial, and all patients were aged $49 years at entry into the trial. More than 95% of patients underwent the assigned repair. The primary outcome was all-cause mortality, and 146 deaths occurred in each group (hazard risk [HR] with endovascular repair vs open repair, 0.97; 95% confidence interval [CI], 0.77-1.22; P ¼ .81). The previously reported reduction in perioperative mortality with endovascular repair was sustained at 2 years (HR, 0.63; 95% CI, 0.40-0.98; P ¼ .04) and at 3 years (HR, 0.72; 95% CI, 0.51-1.00; P ¼ .05) but not thereafter. In the endovascular repair group there were 10 aneurysm-related deaths (2.3%) vs 16 in the open repair group (3.7%; P ¼ .22). Six aneurysm ruptures were confirmed in the endovascular repair group vs none in the open repair group (P ¼ .03). A significant interaction was observed between age and type of treatment (P ¼ .006). Survival was increased among patients aged <70 years in the endovascular repair group but tended to be better among those aged >70 years in the open repair group. The two groups did not differ significantly with respect to number of secondary therapeutic procedures, number of hospitalizations after repair, quality of life, or erectile dysfunction.Comment: Perhaps the most surprising finding in this study was that endovascular repair appears to result in better outcomes among younger patients and in worse outcomes among older patients. The reasons for this are unclear, but perhaps older ...

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Objective The cost of care for diabetic foot ulcers is estimated to be more than $1.5 billion annually. The aim of this study was to analyze inpatient diabetic foot ulcer cost changes over time and to identify factors associated with these costs. Methods The Nationwide Inpatient Sample (2005–2010) was queried using the International Classification of Diseases, Ninth Revision codes for a primary diagnosis of foot ulceration. The primary outcomes were changes in adjusted total hospital charges and costs over time. Multivariable analysis was performed to assess relative increases (RIs) in hospital charges per patient in 2005 vs 2010 adjusting for demographic characteristics, income, comorbidities (Charlson Co-morbidity Index ≥3), insurance type, hospital characteristics, diagnostic imaging, revascularization, amputation, and length of stay. Results Overall, 336,641 patients were admitted with a primary diagnosis of diabetic foot ulceration (mean age, 62.9 ± 0.1 years, 59% male, 61% white race). The annual cumulative cost for inpatient treatment of diabetic foot ulcers increased significantly from 2005 to 2010 ($578,364,261 vs $790,017,704; P < .001). More patients were hospitalized (128.6 vs 152.8 per 100,000 hospitalizations; P < .001), and the mean adjusted cost per patient hospitalization increased significantly over time ($11,483 vs $13,258; P < .001). The proportion of nonelective admissions remained stable (25% vs 23%; P =.32) and there were no differences in mean hospital length of stay (7.0 ± 0.1 days vs 6.8 ± 0.1 days; P =.22). Minor (17.9% vs 20.6%; P < .001), but not major amputations (3.9% vs 4.2%; P = .27) increased over time. Based on multivariable analysis, the main factors contributing to the escalating cost per patient hospitalization included increased patient comorbidities (unadjusted mean difference 2005 vs 2010 $3303 [RI, 1.08] vs adjusted $15,220 [RI, 1.35]), open revascularization (unadjusted $15,145 [RI, 1.25] vs adjusted $30,759 [RI, 1.37]), endovascular revascularization (unadjusted $17,662 [RI, 1.29] vs adjusted $28.937 [RI, 1.38]), and minor amputations (unadjusted $9918 [RI, 1.24] vs adjusted $18,084 [RI, 1.33]) (P < .001, all). Conclusions Hospital charges and costs related to diabetic foot ulcers have increased significantly over time despite stable hospital length of stay and proportion of emergency admissions. Risk-adjusted analyses suggest that this change might be reflective of increasing charges associated with a progressively sicker patient population and attempts at limb salvage. Despite this, the overall incidence of major amputations remained stable.