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.

Vein graft surveillance: Is graft revision without angiography justified and what criteria should be used?

AbstractPurpose: The objective of this study was to assess the accuracy of color-flow duplex surveillance parameters to detect infrainguinal vein graft stenoses and to investigate whether graft revision without angiography is justified. Methods: In a prospective study in which three centers participated, the data of graft surveillance in 300 patients were analyzed. For the evaluation of surveillance criteria all patients underwent a digital subtraction angiography if a graft stenosis was suspected. To create a control group, in patients with normal grafts a consented digital subtraction angiography was performed also. From these data the accuracy of seven duplex and three ankle blood pressure-derived variables was assessed. The relation between various surveillance criteria and continued graft patency was determined with life table analysis with the transient state method. Results: The mean follow-up period was 20 months (range, 1 to 40 months). At univariate and multivariate analysis the peak systolic velocity (PSV) ratio provided the best correlation with angiographic stenoses ≥70% (PSV ratio cutoff 3.0: sensitivity 80%, specificity 84%). This finding did not differ between the participating centers. With life table methods it was demonstrated that the best combination of efficacy (limitation of the number of unnecessary revisions), safety (minimal number of correctable lesions missed), and reduction of angiograms was obtained by a two-parameter surveillance algorithm. This algorithm included a PSV ratio <2.5 to delineate patients in whom a conservative approach without angiography or revision was appropriate, a PSV ratio ≥4.0 to indicate patients in whom vein graft revision without angiography could be scheduled, and a group with PSV ratios between 2.5 and 4.0 in whom angiography was to be performed to determine clinical management on the basis of the stenosis severity. This algorithm had a positive predictive value of 93% and a negative predictive value of 89%. In addition, it resulted in a reduction of the number of angiograms of 49% compared with a policy of angiographies in all patients with a PSV ratio ≥2.5. Conclusions: The best criterion to identify a failing graft is the PSV ratio. With a two-parameter algorithm for vein graft surveillance, the incidence of unnecessary revisions and of missed high-grade lesions was acceptably low, whereas the number of angiograms was reduced by one half. (J Vasc Surg 1998;27:399-413.

The influence of aortic cuffs and iliac limb extensions on the outcome of endovascular abdominal aortic aneurysm repair.

Contains fulltext : 52110.pdf (publisher's version ) (Closed access)BACKGROUND: In a proportion of patients with an endovascular abdominal aortic aneurysm repair (EVAR), aortic cuffs or iliac graft limb extensions are required to enhance sealing or to fix the position of the device. This requirement arises when these goals are not primarily obtained with the basic stent-graft configuration. The aim of this study was to assess the influence of the use of endograft extensions during the primary EVAR procedure on the short- and long-term outcome. METHODS: The study was based on the data of the EUROSTAR registry. Patient and anatomic characteristics, data regarding the procedure, postoperative complications, and the mortality of patients undergoing EVAR were retrieved from the database. Patients were divided into three groups: (1) no extensions, (2) proximal aortic cuffs, and (3) iliac limb extensions. Logistic regression and Cox proportional hazards models were used to compare significant influences of the use of cuffs or extensions on different outcomes relative to control patients, adjusted for patient and anatomic factors. RESULTS: The overall cohort comprised 6668 patients: 4932 (74.0%) without extensions, 259 (3.9%) with an aortic cuff, and 1477 (22.2%) with an iliac endograft extension. Both the 30-day (2.3%-3.9%) and the all-cause mortality rates (23%-27% at 4 years) were similar in the three study groups. The use of proximal cuffs or iliac extensions did not have an effect on the incidence of endoleaks of any type (24%-32% at 4 years). The incidences of device kinking (P = .0344) and secondary transfemoral interventions (P = .0053) during follow-up were increased in patients in whom iliac limb extensions were used. In patients with aortic cuffs, no significant associations with altered outcome were observed. CONCLUSIONS: The use of iliac graft limb extensions at EVAR was associated with a higher incidence of kinking and secondary transfemoral interventions, whereas proximal aortic cuffs did not influence outcome