Age-related trends in utilization and outcome of open and endovascular repair for abdominal aortic aneurysm in the United States, 2001-2006

ObjectiveThis study used a large national administrative in-hospital database to compare utilization and age-specific outcomes between open repair (OAR) and endovascular (EVAR) repair for the treatment of abdominal aortic aneurysm (AAA).MethodsDischarges with the principal International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) procedure codes for EVAR and OAR and principal diagnosis code of intact AAAs were selected from the 2001 to 2006 Nationwide Inpatient Sample (NIS). Weighted least-square regression was used to test the trend of utilization by age. Multiple linear and logistic regression analyses were used to assess the risk-adjusted outcomes.ResultsNationally, the estimated number of elective AAAs treated with EVAR increased from 11,171 in 2001 to 21,725 in 2006 (P = .003). The number of elective AAAs treated with OAR declined from 17,784 to 8451 during the same period (P < .001). By 2006, EVAR was more frequently used than OAR for patients of all ages. Compared with the younger age groups, patients aged ≥85 years had a significant increase in the total number of asymptomatic AAA repairs, driven almost entirely by an increase in the use of EVAR. Compared with open patients, EVAR patients had a significantly shorter length of hospitalization (adjusted mean, 2.99 days [95% confidence interval (CI), 2.97-3.01] vs 8.78 days [95% CI, 8.53-8.57]), less in-hospital mortality (odds ratio [OR], 0.23; 95% CI, 0.19-0.28), fewer in-hospital complications (OR, 0.27; 95% CI, 0.25-0.28), and a higher likelihood of being discharged to home (OR, 3.95; 95% CI, 3.62-4.31). The reduction of complications from the use of EVAR versus OAR was most dramatic for the oldest patients.ConclusionsAs short-term surgical outcomes are consistently improving for patients undergoing AAA repair, elective EVAR has replaced OAR as the more common method of repair in the United States. The introduction of this technology has been rapidly adopted, particularly for the oldest-old surgical patients, aged ≥85 years, who previously may not have been offered surgical intervention for asymptomatic AAA. Further investigation is necessary to examine whether this trend improves the long-term survival and quality of life for this elderly population

Conflict of Interest with Industry and the Challenges for Surgical Education

Conflicts of interest exist everywhere in medicine. Almost every time I repair an abdominal aortic aneurysm, I get paid. When I work with a family to withdraw life support on their loved one, there is..

It’s Big Surgery: Preoperative Expressions of Risk, Responsibility, and Commitment to Treatment after High-risk Operations

Objective To identify the processes surgeons use to establish patient buy-in to postoperative treatments. Background Surgeons generally believe they confirm the patient's commitment to an operation and all ensuing postoperative care, before surgery. How surgeons get buy-in and whether patients participate in this agreement is unknown. Methods We used purposive sampling to identify three surgeons from different subspecialties who routinely perform high-risk operations at each of three distinct medical centers (Toronto, ON; Boston, MA; Madison, WI). We recorded preoperative conversations with three to seven patients facing high-risk surgery with each surgeon (n = 48) and used content analysis to analyze each preoperative conversation inductively. Results Surgeons conveyed the gravity of high-risk operations to patients by emphasizing the operation is “big surgery” and that a decision to proceed invoked a serious commitment for both the surgeon and the patient. Surgeons were frank about the potential for serious complications and the need for intensive care. They rarely discussed the use of prolonged life-supporting treatment, and patients’ questions were primarily confined to logistic or technical concerns. Surgeons regularly proceeded through the conversation in a manner that suggested they believed buy-in was achieved, but this agreement was rarely forged explicitly. Conclusions Surgeons who perform high-risk operations communicate the risks of surgery and express their commitment to the patient's survival. However, they rarely discuss prolonged life-supporting treatments explicitly and patients do not discuss their preferences. It is not possible to determine patients’ desires for prolonged postoperative life support based on these preoperative conversations alone