Association of an Endovascular-First Protocol for Ruptured Abdominal Aortic Aneurysms With Survival and Discharge Disposition

Ullery, Brant W.; Tran, Kenneth; Chandra, Venita; Mell, Matthew W.; Harris, E. John; Dalman, Ronald L.; Lee, Jason T.

doi:10.1001/jamasurg.2015.1861

Cited by 29 publications

(21 citation statements)

References 21 publications

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“…11 The incorporation of standard protocols using an endovascular first approach for the treatment of ruptured AAA in patients with suitable anatomy has achieved some success in improving mortality among patients with ruptured AAAs. 11-16 Moore et al, found reductions in overall mortality from 39% to 17% following implementation. 11 These data were further supported in similar protocols created at the University of Washington which achieved success in reducing mortality from 58 to 35% despite worse baseline renal function in the post-implementation group.…”

Section: Discussionmentioning

confidence: 99%

Significant regional variation exists in morbidity and mortality after repair of abdominal aortic aneurysm

Zettervall

Soden

Buck

et al. 2017

Journal of Vascular Surgery

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Objectives Limited data exist comparing perioperative morbidity and mortality following open and endovascular repair of abdominal aortic aneurysms (EVAR) among regions of the United States. This study aims to evaluate the regional variation in mortality and perioperative outcomes following repair of abdominal aortic aneurysms (AAA). Methods The Vascular Quality Initiative (VQI) was utilized to identify patients undergoing open AAA repair and EVAR between 2009 and 2014. Ruptured and intact aneurysms were evaluated separately, and analysis of intact aneurysms was limited to infrarenal AAAs only. All 16 regions of the VQI were de-identified and those with fewer than 100 open repairs were combined to eliminate the impact of low volume regions. Regional variation was evaluated using chi-square and fisher-exact tests. Regional rates were then compared to current quality benchmarks. Results Perioperative outcomes from 14 regions were compared. Following open repair of intact aneurysms, no significant variation was seen in 30-day or in-hospital mortality; however multiple regions exceeded the SVS benchmark for in-hospital mortality following open repair of intact aneurysms of <5% (Range: 0-7%, P = .55). Following EVAR all regions met the SVS benchmark of <3% (Range 0-1%, P = .75). Significant variation in in-hospital mortality existed following open (14-63%, P = .03) and endovascular (3-32%, P = .03) repair of ruptured aneurysms across VQI regional groups. Following repair of intact aneurysms, wide variation was seen in prolonged length of stay (>7days for open repair: 32-53%, P = .54; >2 days for EVAR: 16-43% P < .01), transfusion (Open: 10-35% P < .01, EVAR: 7-18% P < .01), use of vasopressors (Open: 19-37% P < .01, EVAR: 3-7% P < .01), and post-operative myocardial infarction (Open: 0-13% P < .01, EVAR: 0-3%, P < .01). Following open repair, worsening renal function (6-18%, P = .04) and respiratory complications (6-20%, P = .20) were variable across regions. The frequency of endoleak at completion of EVAR also had considerable variation (15-38%, P < .01). Conclusions Despite limited variation, multiple regions do not meet current benchmarks for in-hospital mortality after open AAA repair for intact aneurysms. Significant regional variation in perioperative outcomes and length of stay exists, and mortality is widely variable following repair for rupture. These data identify important areas for quality improvement initiatives and clinical practice guidelines.

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Section: Discussionmentioning

confidence: 99%

Significant regional variation exists in morbidity and mortality after repair of abdominal aortic aneurysm

Zettervall

Soden

Buck

et al. 2017

Journal of Vascular Surgery

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“…Given the ubiquity of endovascular therapy in the elective treatment of vascular disease and its successful use in vascular emergencies such as ruptured abdominal aortic aneurysm, 19 definitive endovascular treatment of traumatic hemorrhage is becoming increasingly viable. 20 One of the first areas where endovascular treatment was identified as potentially advantageous was bleeding from pelvic fractures.…”

Section: Discussionmentioning

confidence: 99%

Multicenter retrospective study of noncompressible torso hemorrhage

Chang

Fox

Greene

et al. 2017

Journal of Trauma and Acute Care Surgery

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Objective Rational development of technology for rapid control of non-compressible torso hemorrhage (NCTH) requires detailed understanding of what is bleeding. Our objectives were to describe the anatomic location of truncal bleeding in patients presenting with NCTH and compare endovascular (ENDO) versus open (OPEN) management. Methods Retrospective study of adult trauma patients with NCTH admitted to 4 urban level 1 trauma centers in the Houston and San Antonio metropolitan areas in 2008–2012. Inclusion criteria: named axial torso vessel disruption, AIS chest or abdomen ≥3 with shock (base excess <−4) or truncal operation in ≤90 minutes, or pelvic fracture with ring disruption. Exclusion criteria: isolated hip fractures, falls from standing, or prehospital CPR. After dichotomizing into OPEN, ENDO, and resuscitative thoracotomy (RT) groups based on the initial approach to control NCTH, a mixed-effects Poisson regression with robust error variance (controlling for age, mechanism, ISS, shock, hypotension, and severe head injury as fixed effects and site as a random effect) was used to test the hypothesis that ENDO was associated with reduced in-hospital mortality in NCTH patients. Results 543 patients with NCTH underwent ENDO (n=166, 31%), OPEN (n=309, 57%), or RT (n=68, 12%). Anatomic bleeding locations were 25% chest, 41% abdomen, and 31% pelvis. ENDO was used to treat relatively few types of vascular injuries, while OPEN and RT injuries were more diverse. ENDO patients had more blunt trauma (95% vs 34% vs 32%); severe injuries (median ISS 34 vs 27 vs 21), and increased time to intervention (median 298 vs 92 vs 51 min), compared to OPEN and RT. Mortality was 15% vs 20% vs 79%. ENDO was associated with decreased mortality compared to OPEN (RR 0.58, 95% CI 0.46–0.73). Conclusion Although ENDO may reduce mortality in NCTH patients, significant group differences limit the generalizability of this finding. Level of Evidence Level V (Prognostic and Epidemiologic)

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“…During the study period, a shift in the care of patients was performed in the County, and an “EVAR first strategy” was developed, which have been reported by others [2–4, 23, 27]. This started in 2010–2011, and specific analysis has therefore not been analyzed in detail.…”

Section: Discussionmentioning

confidence: 99%

“…The case mix makes all comparisons on outcome difficult between OR and EVAR patients; the EVAR-treated patients are older, but obviously have a different morphology with smaller aneurysms, and require less ICU and hospital stay, as has been shown by others [12, 21, 23]. …”

Section: Discussionmentioning

confidence: 99%

“…It is not certain how influential the patient’s age is on the decision to offer corrective treatment to rAAA patients. Mortality is higher after OR than EVAR according to retrospective studies [12, 21, 23, 24], and this is also reported in the Swedish Vascular Registry [3]. EVAR is a less invasive method than OR, with a lower perioperative complication rate, but randomized trials have failed to show a difference in short-term mortality [25–27].…”

Section: Introductionmentioning

confidence: 87%

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A Majority of Admitted Patients With Ruptured Abdominal Aortic Aneurysm Undergo and Survive Corrective Treatment: A Population‐Based Retrospective Cohort Study

et al. 2016

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BackgroundAbdominal aortic aneurysm (AAA) is an asymptomatic, potentially lethal condition predominantly found in elderly. The mortality is 100 % if rupture occurs and left untreated, but even in treated patients the mortality is substantial. Female sex and treatment with open repair rather than endovascular aortic repair (EVAR) have been reported to negatively affect outcome. The objective was to describe the contemporary care and outcome of all treated and untreated patients with ruptured AAA (rAAA) admitted to hospital.MethodPopulation-based retrospective investigation, including all patients admitted to the emergency departments within Stockholm County diagnosed with rAAA 2009–2013. All identified patients’ charts (n = 297) were analyzed; the study cohort includes 283 verified patients.ResultsMen were in majority [214 (76 %), 69 (24 %) women] and were younger than women (78 vs 82 years, p < 0.001). A majority of patients were treated (212/283, 75 %), a similar proportion of women and men. Untreated patients had a higher mean age (84 vs 77 years, p < 0.001). The proportion treated with EVAR was 27 %, and they were older than OR treated (79 vs 76 years, p = 0.043). Forty-seven percentage of patients admitted with rAAA survived 30 days, and 62 % of treated patients survived 30 days. The 30-day mortality for women and men was similar.ConclusionsOur results and other contemporary series show a shift toward a higher rate of treated patients with rAAA, and improving outcomes, similar for women and men. The increased use of EVAR contributes to this improvement in short-term outcome. High age influences the willingness to treat patients with rAAA.

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Association of an Endovascular-First Protocol for Ruptured Abdominal Aortic Aneurysms With Survival and Discharge Disposition

Cited by 29 publications

References 21 publications

Significant regional variation exists in morbidity and mortality after repair of abdominal aortic aneurysm

Significant regional variation exists in morbidity and mortality after repair of abdominal aortic aneurysm

Multicenter retrospective study of noncompressible torso hemorrhage

A Majority of Admitted Patients With Ruptured Abdominal Aortic Aneurysm Undergo and Survive Corrective Treatment: A Population‐Based Retrospective Cohort Study

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