Life expectancy after endovascular versus open abdominal aortic aneurysm repair: Results of a decision analysis model on the basis of data from EUROSTAR

AbstractBackground/Objectives: Although endovascular abdominal aortic aneurysm (AAA) repair (ENDO) has decreased operative morbidity risks compared with open AAA repair (OPEN), risks of rupture and reintervention are higher after ENDO. We used decision analysis to examine the effect of these competing risks on quality-adjusted life expectancy (QALE) after ENDO and OPEN. Methods: We used a Markov decision-analysis model to simulate hypothetic cohorts of patients undergoing ENDO or OPEN. Patients moved through a multistate transition model according to probabilities derived from the literature, the EUROSTAR database (for ENDO) and Medicare claims data (for OPEN). Our primary outcome measure was QALE after surgery. We used sensitivity analysis to determine which factors most influenced this outcome. Results: In the base-case analysis of 70-year-old men, life expectancy after ENDO was 7.09 quality-adjusted life years compared with 7.03 quality-adjusted life years for OPEN, a difference of 3 weeks. Sensitivity analysis showed that at less than age 64 years, OPEN results in greater QALE. However, the difference in QALE was small (<3 months) across the entire range of ages studied (60 to 85 years). The optimal strategy was sensitive to changes in ENDO and OPEN operative mortality rate, rupture rate after ENDO, late conversion to OPEN rate, ENDO revision rate, and OPEN reoperation rate. However, the difference between OPEN and ENDO strategies was small across the plausible range of most of these variables. Conclusion: For most patients who are candidates for AAA repair, ENDO and OPEN result in similar QALE. Decision analysis suggests that OPEN may be preferred for younger patients with low operative risk and ENDO may be preferred for older patients with higher operative risk. However, given the similarity in overall outcome, patient preference should be weighed heavily in decision making. (J Vasc Surg 2002;36:1112-20.

National trends in utilization, mortality, and survival after repair of type B aortic dissection in the Medicare population

ObjectiveThe application of thoracic endovascular aortic repair (TEVAR) has changed treatment paradigms for thoracic aortic disease. We sought to better define specific treatment patterns and outcomes for type B aortic dissection treated with TEVAR or open surgical repair (OSR).MethodsMedicare patients undergoing type B thoracic aortic dissection repair (2000-2010) were identified by use of a validated International Classification of Diseases, Ninth Revision diagnostic and procedural code–based algorithm. Trends in utilization were analyzed by procedure type (OSR vs TEVAR), and patterns in patient characteristics and outcomes were examined.ResultsTotal thoracic aortic dissection repairs increased by 21% between 2000 and 2010 (2.5 to 3 per 100,000 Medicare patients; P = .001). A concomitant increase in TEVAR was seen during the same interval (0.03 to 0.8 per 100,000; P < .001). By 2010, TEVAR represented 27% of all repairs. TEVAR patients had higher rates of comorbid congestive heart failure (12% vs 9%; P < .001), chronic obstructive pulmonary disease (17% vs 10%; P < .001), diabetes (8% vs 5%; P < .001), and chronic renal failure (8% vs 3%; P < .001) compared with OSR patients. For all repairs, patient comorbidity burden increased over time (mean Charlson comorbidity score of 0.79 in 2000, 1.10 in 2010; P = .04). During this same interval, in-hospital mortality rates declined from 47% to 23% (P < .001), a trend seen in both TEVAR and OSR patients. Whereas in-hospital mortality rates and 3-year survival were similar between patients selected for TEVAR and OSR, there was a trend toward women having slightly lower 3-year survival after TEVAR (60% women vs 63% men; P = .07).ConclusionsSurgical treatment of type B aortic dissection has increased over time, reflecting an increase in the utilization of TEVAR. Overall, type B dissection repairs are currently performed at lower mortality risk in patients with more comorbidities

Original Excluder component overlap from proximal or distal extension during initial repair not correlated with aneurysm sac shrinkage

ObjectivesThe original abdominal Excluder (W.L. Gore & Associates, Flagstaff, Ariz) endoprosthesis has been associated with late aneurysm sac expansion over time from transgraft ultrafiltration of serous fluid. This has been treated by relining the graft with original or low-permeability components. We asked whether additional component overlap of the original graft material resulting from proximal or distal extensions placed at the time of initial repair would influence the rate of late aneurysm sac expansion in the absence of endoleak.MethodsComputed tomography (CT) scans from subjects (n = 120) receiving the original endoprosthesis from the Excluder pivotal trial were measured for total distance of original graft overlap (including contralateral gate, proximal extension, or distal extension overlap) based on reformatted CT scans. This was compared to change in aneurysm sac diameter and volume (as measured in independent laboratories) at the latest time point available. Patients were omitted if they were missing CT scan data (n = 10), their graft was explanted for endoleak (n = 2), they underwent an intervention for endoleak and did not have diameters available after their intervention (n = 3), or if they had a continued endoleak that could account for an increase in aneurysm sac diameter (n = 11). This left 27 patients with more overlapping components than the required contralateral limb/gate overlap (mean follow-up time 40.6 ± 17.0 months) and 67 patients with required gate overlap (mean follow-up time 46.2 ± 15.9 months).ResultsSubjects with increased component overlap (mean overlap 87.1 mm ± 57.4 mm) were not protected from aneurysm sac expansion when compared to those with the minimum required gate overlap (mean overlap 31.2 mm ± 3.4 mm). There was no association of total distance of overlap with aneurysm sac size change by diameter or volume (r2 = 0.00034, P = .86 for diameter and r2 = 0.0019, P = .68 for volume). Increasing percentage of overlap within the aneurysm sac was likewise not associated with aneurysm sac decrease in diameter (r2 = 0.0028, P = .61). Few patients had large percentages of original graft overlap (mean 26.2% ± 14.1% for the increased overlap group and 18.6% ± 5.5% for the required overlap group, P = .0097).ConclusionPartial graft overlap involving multiple original components from proximal and distal extensions is not protective against aneurysm sac expansion due to transgraft ultrafiltration. This suggests that transgraft ultrafiltration is not impeded by having partial double layers of original material. All patients who received the original Excluder and have late aneurysm sac expansion in the absence of endoleak should have as complete relining as feasible with low permeability components if sac shrinkage is the surrogate goal