Decrease in total aneurysm-related deaths in the era of endovascular aneurysm repair

Abstract

OBJECTIVE With the expansion of elective abdominal aortic aneurysm (AAA) repair after the introduction of endovascular aneurysm repair (EVAR), there is a concern that even with a lower operative mortality there could be increasing number of aneurysm related deaths. To evaluate this, we looked at national trends in AAA repair volume as well as mortality after intact and ruptured AAA repair encompassing the introduction of EVAR. METHODS Patients with intact or ruptured AAA undergoing open repair or EVAR and all those with a diagnosis of ruptured AAA were identified within the 1993–2005 Nationwide Inpatient Sample database using ICD-9 diagnosis and procedure codes. The number of repairs, number of rupture diagnoses without repair, number of deaths, and associated mortality rates were measured for each year of the database. Outcomes (mean annual volumes) were compared from the pre-EVAR era (1993–1998) to the post-EVAR era (2001–2005). RESULTS Since introduction, EVAR increased steadily and accounted for 56% of repairs, yet only 27% of the deaths for intact repairs in 2005. The mean annual number of intact repairs increased from 36,122 in the pre-EVAR era to 38,901 in the post-EVAR era while the mean annual number of deaths related to intact AAA repair decreased from 1,693 pre-EVAR to 1,207 post-EVAR (P < .0001). Mortality for all intact AAA repair decreased from 4.0% to 3.1% (P < .0001) pre and post-EVAR but open repair mortality was unchanged (open repair 4.7% to 4.5%, P= .31; EVAR 1.3%). During the same time periods, mean annual number of ruptured repairs decreased from 2,804 to 1,846 and deaths from ruptured AAA repairs decreased from 2,804 to 1,846 (P < .0001). Mortality for ruptured AAA repair decreased from 44.3% to 39.9% (P < .0001) pre and post-EVAR (open repair 44.3% to 39.9%, P< .001; EVAR 32.4%). The overall mean annual number of ruptured AAA diagnoses (9,979 to 7,773, P < .0001) and overall mean annual deaths from a ruptured AAA decreased post-EVAR (5,338 to 3,901, P < .0001). CONCLUSIONS Since the introduction of EVAR, there has been a significant decrease in the annual number of deaths from both intact and ruptured AAA. This coincided with an increase in intact AAA repair after the introduction of EVAR and a decrease in ruptured AAA diagnosis and repair volume.

The Revised Cardiac Risk Index in the new millennium: a single-centre prospective cohort re-evaluation of the original variables in 9,519 consecutive elective surgical patients

“…Almost two decades later, in spite of rapidly changing surgical techniques 15,16 and improvements to clinical diagnostic testing, 11,17,18 the factors identified in the original report are relevant in a modern elective surgical patient population. Through all of the modelling procedures, any combination of the terms (high-risk type of surgery, history of ischemic heart disease, history of congestive heart failure, and history of cerebrovascular disease) remained discriminatory.…”

Surgical conversion with graft salvage as a definitive treatment for persistent type II endoleak causing sac enlargement

“…1,2 Some concerns remain regarding the durability of the materials, 3 because the rate of reintervention reported in literature reaches 35%. [4][5][6] Despite this, within 5 years, the percentage of patients with abdominal aortic aneurysm undergoing EVAR in the United States increased from 39% to 72%, and the number of patients undergoing open repair declined dramatically.…”

“…Furthermore, 65% of reinterventions are caused by persistent type II endoleak, 8 which is one of the most frequent complications of EVAR, with an incidence of 10% to 30%. [1][2][3] However, given the consistent percentage of stable or regressive type II endoleak, the need for treatment remains controversial. 4,6,9 According to the European Collaborators on Stent-Graft Techniques for Abdominal Aortic Aneurysm Repair (EUROSTAR) database, most type II endoleaks will thrombose spontaneously and have a benign course.…”

Role of molecular imaging with positron emission tomographic in aortic aneurysms

“…Over the last few decades, the incidence of ruptured AAA has declined. This is attributed to the implementation of AAA screening programs and new therapeutics (35). However, novel imaging modalities are required to better stratify AAA at risk of rupture and those that will benefit from repair.…”