Rural Hospitals Face a Higher Burden of Ruptured Abdominal Aortic Aneurysm and are More Likely to Transfer Patients for Emergent Repair

Abstract

itored consecutive patients with MRI-proven sCAD by duplex ultrasound imaging daily in the hospital, monthly for the first 6 months after discharge, and every 6 months thereafter.The authors studied 105 sCADs in 76 patients. The mean follow-up was 58 months (range, 28-96 months). Of the 105 dissections in this study, 61 (58.1%) involved the internal carotid artery and 44 (41.9%) involved the vertebral artery. Four patients had multiple sCADs. Follow-up was available for 74 (103 vessels) of the 76 patients (97.3%). Complete and hemodynamically significant (Ͻ50% stenosis) recanalization rates were 51.4% and 20.4%. All but one of the complete recanalizations occurred within the first 9 months after the initial event. Early recurrences (in-hospital recurrence) were common, with a second sCAD occurring in 20 previously unaffected arteries. There were only two late recurrences (2.7%) at a site of a previous sCAD. Six patients had a family history of arterial dissection and all had a sCAD recurrence. Recurrence rate in patients without a family history of arterial dissection was much less, with only 16 arteries (22.8%) affected (P Ͻ .001).Comment: There are several interesting points here. First, although recurrence of sCAD is reasonably uncommon, it generally occurs early after the initial event and in a different cervical artery. The authors' early recurrence of 25% is much higher than previously suspected and may relate to the rigorous follow-up protocol in the study. The fact that late sCAD recurrence can happen in previously affected artery suggests recurrence after sCAD in the early and late periods may have different pathologies. Perhaps, as the authors point out, early recurrences are correlated with a transient arterial disorder, such as a vasculitis, while late recurrences may be indicative of underlying persistent connective tissue weakness. The high early recurrence rate suggests that aggressive treatment of sCADs, including control of double product and lowering blood pressure within the constraints imposed by the neurologic pathology, should be implemented.

Incidence and outcomes of ruptured abdominal aortic aneurysms in rural and urban Australia

“…It is also likely that the most complex patients are transferred from regional to urban hospitals, reducing median length of stay in rural areas while increasing it in urban areas. Outcomes of elective AAA repair in the USA are worse in rural than urban hospitals, with repair volume of less than 15 per year increasing mortality rate by an odds ratio of 1.3–1.7 . Additionally, a US population study found that shifting AAA repairs to high‐volume centres (not merely from rural to urban, but even from urban to specialist‐urban centres) reduced mortality by 23%, and there is currently argument as to whether AAA repairs should be performed at high‐volume centres only .…”

“…The health of rural and regional populations in Australia is significantly worse than urban populations, with higher rates of preventative disease and all‐cause mortality . The USA similarly suffers marked geographic variation in access to and quality of health care received, with rural hospitals experiencing twice the ruptured AAA presentations, with subsequently increased mortality . Furthermore, rural hospitals are more likely to transfer ruptured AAA patients to larger centres for management, with the resultant delay in repair thus increasing mortality .…”

“…The USA similarly suffers marked geographic variation in access to and quality of health care received, with rural hospitals experiencing twice the ruptured AAA presentations, with subsequently increased mortality . Furthermore, rural hospitals are more likely to transfer ruptured AAA patients to larger centres for management, with the resultant delay in repair thus increasing mortality . This is of great concern to rural communities, as AAA rupture not only causes mortality in 1% of the elderly population, but an increase in odds ratio of 2.5 in rural communities makes AAA rupture a significant public health issue, with disproportionate burden of disease when compared to urban communities.…”

The effect of surgeon specialization on outcomes after ruptured abdominal aortic aneurysm repair

“…11 This improvement in outcomes at high-volume aortic centers has also been seen for rAAA repair. 15 Finally, Maybury et al 16 reported a significant decrease in hospital death after rAAA repair in areas with a higher density of vascular surgeons. Current literature supports the notion that "practice makes perfect" in abdominal aortic work.…”

Abdominal Aortic Aneurysm : Aspects on how to affect mortality from rupture

“…An American study concluded that rural hospitals face a disproportionate burden of rAAA and are more likely to transfer patients with rAAA without performing repair, compared to urban hospitals (Maybury, Chang & Freischlag 2011). However, they did not demonstrate a survival disadvantage for patients with rAAA admitted to rural hospitals, but then only operative mortality rate was studied.…”