The consequences of real life practice of early abdominal aortic aneurysm repair: a cost-benefit analysis

Background: The reported 54 mm median intervention diameter for endovascular aneurysm repair (EVAR) in the Vascular Quality Initiative and European data from the Pharmaceutical Aneurysm Stabilisation Trial (PHAST) implies that in real life the majority of abdominal aortic aneurysm (AAA) repairs occur at diameters smaller than the consensus intervention threshold of 55 mm. This study explores the potential consequences of this practice. Methods: The differences between real life AAA repair and consensus based intervention threshold were explored in reported data from vascular quality initiatives and PHAST. The subsequent consequences of advancement of endovascular aneurysm repair (EVAR) were estimated using a multistate model based on life tables for the EVAR Medicare population. Results: There appears an approximate 5 mm difference in AAA diameter between real life practice and consensus intervention threshold. Assuming a 2.5 mm annual growth rate, this results in an approximately 2 year advancement of AAA repair. According to the model used, early repair reduces overall small aneurysm patient mortality by 2.3%, it results in 21.9% more EVAR procedures, more EVAR related deaths, and 42.3% and 36.8% more open and endovascular re-interventions, respectively. Cost benefit estimates imply 482 fewer AAA related deaths, but 140 extra EVAR related deaths for a population of more than 30,000 AAA patients, and a 300 million USD increase in health costs for the 8 year observation period in the Medicare population. Conclusions: In the real life situation a large proportion of EVAR procedures appear to occur before reaching the consensus threshold. Although this reduces mortality, it comes at a cost of approximately 1 million USD per prevented rupture related death

National and Regional Differences in 32,248 Postmastectomy Autologous Breast Reconstruction Using the Updated National Inpatient Survey

Item does not contain fulltextBACKGROUND: The incidence of breast cancer (BC) cases has increased significantly. The number of breast reconstruction (BR) procedures performed has mirrored this trend. Although implant-only procedures remain the most commonly used type of immediate BR, autologous techniques involving donor sites account for approximately 20%. The aim of this study was to assess national and regional trends in different types of autologous BR. METHODS: Using the Nationwide Inpatient Sample database (2008 to 2012), data on BC and mastectomy rates, type of autologous BR, and sociodemographics were obtained and analyzed. Furthermore, national and regional trends over time for autologous BR were plotted and analyzed. RESULTS: A total of 427,272 patients diagnosed with BC or at increased risk of BC were included in the study. A total of 343,163 (80.3%) patients underwent mastectomy and, within this group, 148,700 (43.3%) patients underwent immediate BR. Of these, 32,249 (21.7%) patients underwent an autologous BR (not solely implant based) and 118,258 (78.3%) implant-based BR. Most autologous BRs were performed in the Southern region (37.4%). When stratified into flap types, most pedicled transverse rectus abdominis muscle (TRAM), free TRAM, and other flaps were performed in the Northeast region, whereas most deep inferior epigastric perforator (DIEP) and latissimus dorsi (LD) flaps were performed in the Southern region. Subgroup analysis demonstrated a significant increasing trend for both LD and DIEP flaps, both nationally (P < 0.001) and regionally (P < 0.001). Pedicled TRAM and free TRAM reconstructions decreased significantly both on national and regional level. CONCLUSIONS: Autologous BR demonstrated a significant positive trend over time in the Southern region (P < 0.001). The DIEP and LD flaps increased significantly over time, both nationally and regionally

Differences in the Reporting of Racial and Socioeconomic Disparities among Three Large National Databases for Breast Reconstruction

Item does not contain fulltextBACKGROUND: Research derived from large-volume databases plays an increasing role in the development of clinical guidelines and health policy. In breast cancer research, the Surveillance, Epidemiology and End Results, National Surgical Quality Improvement Program, and Nationwide Inpatient Sample databases are widely used. This study aims to compare the trends in immediate breast reconstruction and identify the drawbacks and benefits of each database. METHODS: Patients with invasive breast cancer and ductal carcinoma in situ were identified from each database (2005-2012). Trends of immediate breast reconstruction over time were evaluated. Patient demographics and comorbidities were compared. Subgroup analysis of immediate breast reconstruction use per race was conducted. RESULTS: Within the three databases, 1.2 million patients were studied. Immediate breast reconstruction in invasive breast cancer patients increased significantly over time in all databases. A similar significant upward trend was seen in ductal carcinoma in situ patients. Significant differences in immediate breast reconstruction rates were seen among races; and the disparity differed among the three databases. Rates of comorbidities were similar among the three databases. CONCLUSIONS: There has been a significant increase in immediate breast reconstruction; however, the extent of the reporting of overall immediate breast reconstruction rates and of racial disparities differs significantly among databases. The Nationwide Inpatient Sample and the National Surgical Quality Improvement Program report similar findings, with the Surveillance, Epidemiology and End Results database reporting results significantly lower in several categories. These findings suggest that use of the Surveillance, Epidemiology and End Results database may not be universally generalizable to the entire U.S. POPULATION

Conversion from endovascular to open abdominal aortic aneurysm repair

Background Previous studies have found conflicting results regarding the operative risks associated with conversion to open abdominal aortic aneurysm (AAA) repair after failed endovascular treatment (endovascular aneurysm repair [EVAR]). The purpose of this study was to assess the outcome of patients undergoing a conversion, and compare outcomes with standard open AAA repair and EVAR. In addition, we sought out to identify factors associated with conversion. Methods All patients undergoing a conversion to open repair, and those undergoing standard EVAR and open repair between 2005 and 2013 were included from the National Surgical Quality Improvement Program. Multivariable logistic regression analysis was used to identify factors associated with conversion, and to assess independent perioperative risks associated with conversion compared with standard AAA repair. Subanalysis for factors associated with conversion was performed among patients additionally included in the more detailed targeted vascular module of the National Surgical Quality Improvement Program. Results A total of 32,164 patients were included, with 300 conversions, 7188 standard open repairs, and 24,676 EVARs. Conversion to open repair was associated with a significantly higher 30-day mortality than standard open repair (10.0% vs 4.2%; odds ratio [OR], 2.4; 95% confidence interval [CI], 1.6-3.6; P 30 was negatively associated with (OR, 0.7; 95% CI, 0.5-0.9). Among anatomic characteristics captured in the targeted vascular data set (n = 4555), large aneurysm diameter demonstrated to be strongly associated with conversion (OR, 1.1 per 1 cm increase; 95% CI, 1.03-1.1). Conclusions Conversion to open repair after failed EVAR is associated with substantially increased perioperative morbidity and mortality compared with standard AAA repair. Factors associated with conversion are large diameter of the aneurysm, young age, female gender, and nonwhite race, whereas obesity is inversely related to conversion surgery

Incidence of and risk factors for bowel ischemia after abdominal aortic aneurysm repair

Background Bowel ischemia is a rare but devastating complication after abdominal aortic aneurysm (AAA) repair. Its rarity has prohibited extensive risk-factor analysis, particularly since the widespread adoption of endovascular AAA repair (EVAR); therefore, this study assessed the incidence of postoperative bowel ischemia after AAA repair in the endovascular era and identified risk factors for its occurrence. Methods All patients undergoing intact or ruptured AAA repair in the Vascular Study Group of New England (VSGNE) between January 2003 and November 2014 were included. Patients with and without postoperative bowel ischemia were compared and stratified by indication (intact and ruptured) and treatment approach (open repair and EVAR). Criteria for diagnosis were endoscopic or clinical evidence of ischemia, including bloody stools, in patients who died before diagnostic procedures were performed. Independent predictors of postoperative bowel ischemia were established using multivariable logistic regression analysis. Results Included were 7312 patients, with 6668 intact (67.0% EVAR) and 644 ruptured AAA repairs (31.5% EVAR). The incidence of bowel ischemia after intact repair was 1.6% (open repair, 3.6%; EVAR, 0.6%) and 15.2% after ruptured repair (open repair, 19.3%; EVAR, 6.4%). Ruptured AAA was the most important determinant of postoperative bowel ischemia (odds ratio [OR], 6.4, 95% confidence interval [CI], 4.5-9.0), followed by open repair (OR, 2.9; 95% CI, 1.8-4.7). Additional predictive patient factors were advanced age (OR, 1.4 per 10 years; 95% CI, 1.1-1.7), female gender (OR, 1.6; 95% CI, 1.1-2.2), hypertension (OR, 1.8; 95% CI, 1.1-3.0), heart failure (OR, 1.8; 95% CI, 1.2-2.8), and current smoking (OR, 1.5; 95% CI, 1.1-2.1). Other risk factors included unilateral interruption of the hypogastric artery (OR, 1.7; 95% CI, 1.0-2.8), prolonged operative time (OR, 1.2 per 60-minute increase; 95% CI, 1.1-1.3), blood loss >1 L (OR, 2.0; 95% CI, 1.3-3.0), and a distal anastomosis to the femoral artery (OR, 1.7; 95% CI, 1.1-2.7). Bowel ischemia patients had a significantly higher perioperative mortality after intact (open repair: 20.5% vs 1.9%; P <.001; EVAR: 34.6% vs 0.9%; P <.001) as well as after ruptured AAA repair (open repair: 48.2% vs 25.6%; P <.001; EVAR: 30.8% vs 21.1%; P <.001). Conclusions This study underlines that although bowel ischemia after AAA repair is rare, the associated outcomes are very poor. The cause of postoperative bowel ischemia is multifactorial and can be attributed to patient factors and operative characteristics. These data should be considered during preoperative risk assessment and for optimization of both the patient and the procedure in an effort to reduce the risk of postoperative bowel ischemia

National trends in utilization and outcome of thoracic endovascular aortic repair for traumatic thoracic aortic injuries

Abstract Introduction Endovascular repair of traumatic thoracic aortic injuries (TTAI) is an alternative to conventional open surgical repair. Single institution studies have shown a survival benefit with TEVAR, but it is not clear if this is being realized nationally. The purpose of our study was to document trends in the increase in utilization of TEVAR and its impact on outcomes of TTAI nationally. Methods Patients admitted with a traumatic thoracic aortic injury between 2005 and 2011 were identified in the National Inpatient Sample (NIS). Patients were grouped by treatment into TEVAR, open repair, or nonoperative management groups. Primary outcomes were relative utilization over time and in-hospital mortality. Secondary outcomes included postoperative complications and length of stay. Multivariable logistic regression was performed to identify independent predictors of mortality. Results A total of 8384 patients were included, with 2492 (29.7%) undergoing TEVAR, 848 (10.1%) open repair, and 5044 (60.2%) managed nonoperatively. TEVAR has b

Risk factors for 30-day unplanned readmission following infrainguinal endovascular interventions

Objective Unplanned hospital readmissions following surgical interventions are associated with adverse events and contribute to increasing health care costs. Despite numerous studies defining risk factors following lower extremity bypass surgery, evidence regarding readmission after endovascular interventions is limited. This study aimed to identify predictors of 30-day unplanned readmission following infrainguinal endovascular interventions. Methods We identified all patients undergoing an infrainguinal endovascular intervention in the targeted vascular module of the American College of Surgeons National Surgical Quality Improvement Program between 2012 and 2014. Perioperative outcomes were stratified by symptom status (chronic limb-threatening ischemia [CLI] vs claudication). Patients who died during index admission and those who remained in the hospital after 30 days were excluded. Indications for unplanned readmission related to the index procedure were evaluated. Multivariable logistic regression was used to identify preoperative and in-hospital (during index admission) risk factors of 30-day unplanned readmission. Results There were 4449 patients who underwent infrainguinal endovascular intervention, of whom 2802 (63%) had CLI (66% tissue loss) and 1647 (37%) had claudication. The unplanned readmission rates for CLI and claudication patients were 16% (n = 447) and 6.5% (n = 107), respectively. Mortality after index admission was higher for readmitted patients compared with those not readmitted (CLI, 3.4% vs 0.7% [P < .001]; claudication, 2.8% vs 0.1% [P < .01]). Approximately 50% of all unplanned readmissions were related to the index procedure. Among CLI patients, the most common indication for readmission related to the index procedure was wound or infection related (42%), whereas patients with claudication were mainly readmitted for recurrent symptoms of peripheral vascular disease (28%). In patients with CLI, predictors of unplanned readmission included diabetes (odds ratio, 1.3; 95% confidence interval, 1.01-1.6), congestive heart failure (1.6; 1.1-2.5), renal insufficiency (1.7; 1.3-2.2), preoperative dialysis (1.4; 1.02-1.9), tibial angioplasty/stenting (1.3; 1.04-1.6), in-hospital bleeding (1.9; 1.04-3.5), in-hospital unplanned return to the operating room (1.9; 1.1-3.5), and discharge other than to home (1.5; 1.1-2.0). Risk factors for those with claudication were dependent functional status (3.5; 1.4-8.7), smoking (1.6; 1.02-2.5), diabetes (1.5; 1.01-2.3), preoperative dialysis (3.6; 1.6-8.3), procedure time exceeding 120 minutes (1.8; 1.1-2.7), in-hospital bleeding (2.9; 1.2-7.4), and in-hospital unplanned return to the operating room (3.4; 1.2-9.4). Conclusions Unplanned readmission after endovascular treatment is relatively common, especially in patients with CLI, and is associated with substantially increased mortality. Awareness of these risk factors will help providers identify patients at high risk who may benefit from early surveillance, and prophylactic measures focused on decreasing postoperative complications may reduce the rate of readmission

Predictive ability of the Society for Vascular Surgery Wound, Ischemia, and foot Infection (WIfI) classification system following infrapopliteal endovascular interventions for critical limb ischemia

Objective The Society for Vascular Surgery (SVS) Lower Extremity Guidelines Committee has composed a new threatened lower extremity classification system that reflects the three major factors that impact amputation risk and clinical management: Wound, Ischemia, and foot Infection (WIfI). Our goal was to evaluate the predictive ability of this scale following any infrapopliteal endovascular intervention for critical limb ischemia (CLI). Methods From 2004 to 2014, a single institution, retrospective chart review was performed at the Beth Israel Deaconess Medical Center for all patients undergoing an infrapopliteal angioplasty for CLI. Throughout these years, 673 limbs underwent an infrapopliteal endovascular intervention for tissue loss (77%), rest pain (13%), stenosis of a previously treated vessel (5%), acute limb ischemia (3%), or claudication (2%). Limbs missing a grade in any WIfI component were excluded. Limbs were stratified into clinical stages 1 to 4 based on the SVS WIfI classification for 1-year amputation risk, as well as a novel WIfI composite score from 0 to 9. Outcomes included patient functional capacity, living status, wound healing, major amputation, major adverse limb events, reintervention, major amputation, or stenosis (RAS) events (> ×3.5 step-up by duplex), amputation-free survival, and mortality. Predictors were identified using Kaplan-Meier survival estimates and Cox regression models. Results Of the 596 limbs with CLI, 551 were classified in all three WIfI domains on a scale of 0 (least severe) to 3 (most severe). Of these 551, 84% were treated for tissue loss and 16% for rest pain. A Cox regression model illustrated that an increase in clinical stage increases the rate of major amputation (hazard ratio [HR], 1.6; 95% confidence interval [CI], 1.1-2.3). Separate regression models showed that a one-unit increase in the WIfI composite score is associated with a decrease in wound healing (HR, 1.2; 95% CI, 1.1-1.4) and an increase in the rate of RAS events (HR, 1.2; 95% CI, 1.1-1.4) and major amputations (HR, 1.4; 95% CI, 1.2-1.8). Conclusions This study supports the ability of the SVS WIfI classification system to predict 1-year amputation, RAS events, and wound healing in patients with CLI undergoing endovascular infrapopliteal revascularization procedures