Predictors of morbidity and mortality with endovascular and open thoracic aneurysm repair

BackgroundOpen and endovascular thoracic aneurysm repairs are associated with significant complications including paraplegia, stroke, vascular insufficiency, and death. Predictors of adverse outcomes are not well-defined in this patient population.MethodsThe database of the GORE TAG (W.L. Gore, Flagstaff, Ariz) Pivotal Trial comparing the TAG endograft to open repair was interrogated. Univariate (UVA) and multivariate analyses (MVA) of demographic, clinical, anatomic, and procedural variables were conducted to discover possible predictors of serious adverse events for the whole group and for the TAG and open cohort groups separately. Early adverse outcomes occurred within 30 days or the initial hospitalization. P value of ≤ .05 was significant.ResultsA total of 140 TAG and 94 open descending thoracic aneurysm (DTA) patients were analyzed, consisting of 128 men and 106 women. Perioperative deaths were 9/94 for open surgery and 3/140 for TAG patients, with 10/12 (7 open, 3 TAG) deaths occurring in men. Two female deaths were both after open surgery. Multivariate analysis showed predictors of death for all patients were symptomatic aneurysms and male gender. Analysis of a combined morbidity/mortality endpoint (stroke/paralysis/MI/death) showed elevated creatinine predicted these events for the whole group. Open surgery (P < .001) and increasing aneurysm diameter (P < .001) predicted an increased likelihood of any major adverse event. Open surgery was significantly associated with an increased risk of paraplegia (P = .002). Vascular complications were more frequent in the TAG (19%) than in open DTA patients (9%) (P = .038). Female gender (P = .01) predicted vascular complications within the endovascular group. For all analyses, long procedure times were correlated with adverse events. Women were noted to have longer procedure times for both TAG and open repairs.ConclusionElevated creatinine levels and symptomatic aneurysms predict morbidity and mortality, respectively, regardless of repair type. Male gender predicted death after open surgery, and since most deaths (9 of 12) were in this group, male gender predicted death overall, despite women's more difficult endovascular TAA repairs as evidenced by longer procedure times and higher vascular complication rates. All major adverse events and paraplegia were more common for open surgery patients

Improving aneurysm-related outcomes: Nationwide benefits of endovascular repair

ObjectivesEndovascular aneurysm repair (EVAR) has changed the practice of abdominal aortic aneurysm (AAA) surgery. We examined a national Medicare database to establish the effect of EVAR introduction into the United States.MethodsA 5% random sample of inpatient Medicare claims from 2000 to 2003 was queried using International Classification of Diseases, 9th Revision (ICD-9) diagnosis and procedure codes. An EVAR procedure code was available after October 2000. Occurrences were multiplied by 20 to estimate yearly national volumes and then divided into the yearly Centers for Medicare and Medicaid Services (CMS) population of elderly Medicare recipients for rates per capita, reported as cases per 100,000 elderly Medicare recipients. Statistical analysis was performed by using χ2, Student’s t test, nonparametric tests, and multiple regression analysis, with significance defined as P ≤ .05.ResultsElective AAA repairs averaged 87.7 per 100,000 Medicare patients between 2000 and 2003, with EVAR has steadily increasing to 41% of elective repairs in 2003. From 2000 to 2003, overall elective AAA mortality declined from 5.0% to 3.7% (P < .001), while open repair mortality remained unchanged. EVAR patients are significantly older than patients treated with open repair. From 2000 to 2003 patients >84 years receiving EVAR increased to 62.7% (P < .001). Overall hospital length of stay (LOS) decreased from 8.6 days in 2000 to 7.3 days in 2003, P < .001, but increased for open AAA patients. EVAR patients were more likely to be discharged home rather than to skilled facilities. Average elective repair hospital charges were not different between groups, but Medicare reimbursement was lower for EVAR, with a higher proportion cases classified as DRG 111 (major cardiovascular procedure without complications). EVAR was used in 10.6% of ruptured AAA repairs in 2003, with a significant reduction in mortality compared with open repairs for rupture (31.8% vs 50.8%; P < .001).ConclusionsEVAR is replacing open surgery without an increase in overall case volume. EVAR is responsible for overall decrease in operative mortality even in ruptured aneurysms while decreasing utilization variables. Reimbursement to hospitals is shrinking, however

Late Transitions and Bereaved Family Member Perceptions of Quality of End‐of‐Life Care

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/146458/1/jgs15455.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/146458/2/jgs15455_am.pd