Long-term outcomes and factors influencing late survival following elective abdominal aortic aneurysm repair: A 24-year experience

Khashram, Manar; Jenkins, Jason; Kruger, Allan; Boyne, Nicholas; Foster, W.; Walker, Philip J.

doi:10.1177/1708538115586682

Cited by 23 publications

(24 citation statements)

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“…They identified age, female sex, American Society of Anesthesiologists class, COPD, peripheral arterial disease, renal impairment, and heart failure as factors associated with late death. 11 This is similar to a review of 247 patients treated with EVAR reported by Lim et al, in which they identified advanced age, renal disease, and oxygen-dependent COPD as predictors of overall mortality. In addition, advanced heart failure (ejection fraction <40%) and current cancer treatment were major predictors.…”

Section: Discussionsupporting

confidence: 86%

“…11 Although our study is limited to overall mortality, they delineated that cardiac, respiratory, and oncologic causes remain the leading causes of death for patients after AAA repair (accounting for two-thirds of late deaths). They identified age, female sex, American Society of Anesthesiologists class, COPD, peripheral arterial disease, renal impairment, and heart failure as factors associated with late death.…”

Section: Discussionmentioning

confidence: 98%

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External validation of a 5-year survival prediction model after elective abdominal aortic aneurysm repair

DeMartino

Huang

Mandrekar³

et al. 2018

Journal of Vascular Surgery

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Objective The benefit of prophylactic repair of abdominal aortic aneurysms (AAAs) is based on the risk of rupture exceeding the risk of death from other comorbidities. The purpose of this study was to validate a 5-year survival prediction model for patients undergoing elective repair of asymptomatic AAA <6.5 cm to assist in optimal selection of patients. Methods All patients undergoing elective repair for asymptomatic AAA <6.5 cm (open or endovascular) from 2002 to 2011 were identified from a single institutional database (validation group). We assessed the ability of a prior published Vascular Study Group of New England (VSGNE) model (derivation group) to predict survival in our cohort. The model was assessed for discrimination (concordance index), calibration (calibration slope and calibration in the large), and goodness of fit (score test). Results The VSGNE derivation group consisted of 2367 patients (70% endovascular). Major factors associated with survival in the derivation group were age, coronary disease, chronic obstructive pulmonary disease, renal function, and antiplatelet and statin medication use. Our validation group consisted of 1038 patients (59% endovascular). The validation group was slightly older (74 vs 72 years; P < .01) and had a higher proportion of men (76% vs 68%; P < .01). In addition, the derivation group had higher rates of advanced cardiac disease, chronic obstructive pulmonary disease, and baseline creatinine concentration (1.2 vs 1.1 mg/dL; P < .01). Despite slight differences in preoperative patient factors, 5-year survival was similar between validation and derivation groups (75% vs 77%; P = .33). The concordance index of the validation group was identical between derivation and validation groups at 0.659 (95% confidence interval, 0.63–0.69). Our validation calibration in the large value was 1.02 (P = .62, closer to 1 indicating better calibration), calibration slope of 0.84 (95% confidence interval, 0.71–0.97), and score test of P = .57 (>.05 indicating goodness of fit). Conclusions Across different populations of patients, assessment of age and level of cardiac, pulmonary, and renal disease can accurately predict 5-year survival in patients with AAA <6.5 cm undergoing repair. This risk prediction model is a valid method to assess mortality risk in determining potential overall survival benefit from elective AAA repair.

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Section: Discussionsupporting

confidence: 86%

Section: Discussionmentioning

confidence: 98%

External validation of a 5-year survival prediction model after elective abdominal aortic aneurysm repair

DeMartino

Huang

Mandrekar³

et al. 2018

Journal of Vascular Surgery

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“…Another similar longitudinal study has been reported in 2015 . The objective of this study was to assess predictors of long‐term survival and compared elective open abdominal aortic aneurysm repairs and endovascular repairs as an institutional experience.…”

Section: Discussionmentioning

confidence: 83%

Long‐term survival following open repair of ruptured abdominal aortic aneurysm

Englund

Katib

2016

ANZ Journal of Surgery

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“…The per-protocol analysis hinted at some benefit in patients who actually underwent EVAR. A recent observational study from a single institution in Queensland, Australia, 109 reported no differences in 5-, 10-and 15-year survival rates between OR (n = 982, median follow-up 6.5 years) and EVAR (n = 358, median follow-up 4.0 years), but suffered from incomplete patient reporting. The EUROpean collaborators on Stent-graft Techniques for abdominal aortic Aneurysm Repair (EUROSTAR) database has reported that rate of secondary sac rupture after EVAR is low for the first 4 years, but after this time the rate appears to increase, particularly in those with known sac expansion.…”

Section: Evar Trialmentioning

confidence: 96%

The UK EndoVascular Aneurysm Repair (EVAR) randomised controlled trials: long-term follow-up and cost-effectiveness analysis

Patel

Powell

Sweeting

et al. 2018

Health Technol Assess

101

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BackgroundShort-term survival benefits of endovascular aneurysm repair (EVAR) compared with open repair (OR) of intact abdominal aortic aneurysms have been shown in randomised trials, but this early survival benefit is soon lost. Survival benefit of EVAR was unclear at follow-up to 10 years.ObjectiveTo assess the long-term efficacy of EVAR against OR in patients deemed fit and suitable for both procedures (EVAR trial 1; EVAR-1); and against no intervention in patients unfit for OR (EVAR trial 2; EVAR-2). To appraise the long-term significance of type II endoleak and define criteria for intervention.DesignTwo national, multicentre randomised controlled trials: EVAR-1 and EVAR-2.SettingPatients were recruited from 37 hospitals in the UK between 1 September 1999 and 31 August 2004.ParticipantsMen and women aged ≥ 60 years with an aneurysm of ≥ 5.5 cm (as identified by computed tomography scanning), anatomically suitable and fit for OR were randomly assigned 1 : 1 to either EVAR (n = 626) or OR (n = 626) in EVAR-1 using computer-generated sequences at the trial hub. Patients considered unfit were randomly assigned to EVAR (n = 197) or no intervention (n = 207) in EVAR-2. There was no blinding.InterventionsEVAR, OR or no intervention.Main outcome measuresThe primary end points were total and aneurysm-related mortality until mid-2015 for both trials. Secondary outcomes for EVAR-1 were reinterventions, costs and cost-effectiveness.ResultsIn EVAR-1, over a mean of 12.7 years (standard deviation 1.5 years; maximum 15.8 years), we recorded 9.3 deaths per 100 person-years in the EVAR group and 8.9 deaths per 100 person-years in the OR group [adjusted hazard ratio (HR) 1.11, 95% confidence interval (CI) 0.97 to 1.27;p = 0.14]. At 0–6 months after randomisation, patients in the EVAR group had a lower mortality (adjusted HR 0.61, 95% CI 0.37 to 1.02 for total mortality; HR 0.47, 95% CI 0.23 to 0.93 for aneurysm-related mortality;p = 0.031), but beyond 8 years of follow-up patients in the OR group had a significantly lower mortality (adjusted HR 1.25, 95% CI 1.00 to 1.56,p = 0.048 for total mortality; HR 5.82, 95% CI 1.64 to 20.65,p = 0.0064 for aneurysm-related mortality). The increased aneurysm-related mortality in the EVAR group after 8 years was mainly attributable to secondary aneurysm sac rupture, with increased cancer mortality also observed in the EVAR group. Overall, aneurysm reintervention rates were higher in the EVAR group than in the OR group, 4.1 and 1.7 per 100 person-years, respectively (p < 0.001), with reinterventions occurring throughout follow-up. The mean difference in costs over 14 years was £3798 (95% CI £2338 to £5258). Economic modelling based on the outcomes of the EVAR-1 trial showed that the cost per quality-adjusted life-year gained over the patient’s lifetime exceeds conventional thresholds used in the UK. In EVAR-2, patients died at the same rate in both groups, but there was suggestion of lower aneurysm mortality in those who actually underwent EVAR. Type II endoleak itself is not associated with a higher rate of mortality.LimitationsDevices used were implanted between 1999 and 2004. Newer devices might have better results. Later follow-up imaging declined, particularly for OR patients. Methodology to capture reinterventions changed mainly to record linkage through the Hospital Episode Statistics administrative data set from 2009.ConclusionsEVAR has an early survival benefit but an inferior late survival benefit compared with OR, which needs to be addressed by lifelong surveillance of EVAR and reintervention if necessary. EVAR does not prolong life in patients unfit for OR. Type II endoleak alone is relatively benign.Future workTo find easier ways to monitor sac expansion to trigger timely reintervention.Trial registrationCurrent Controlled Trials ISRCTN55703451.FundingThis project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and the results will be published in full inHealth Technology Assessment; Vol. 22, No. 5. See the NIHR Journals Library website for further project information.

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Long-term outcomes and factors influencing late survival following elective abdominal aortic aneurysm repair: A 24-year experience

Cited by 23 publications

References 32 publications

External validation of a 5-year survival prediction model after elective abdominal aortic aneurysm repair

External validation of a 5-year survival prediction model after elective abdominal aortic aneurysm repair

Long‐term survival following open repair of ruptured abdominal aortic aneurysm

The UK EndoVascular Aneurysm Repair (EVAR) randomised controlled trials: long-term follow-up and cost-effectiveness analysis

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