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Editor's Choice - The Impact of Centralisation and Endovascular Aneurysm Repair on Treatment of Ruptured Abdominal Aortic Aneurysms Based on International Registries
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery. Aarhus Univ Hosp, Dept Cardiothorac & Vasc Surg, Aarhus, Denmark.
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.ORCID iD: 0000-0001-6561-9734
Helsinki Univ Hosp, Dept Vasc Surg, Helsinki, Finland.
Univ Heart Ctr Hamburg Eppendorf, Dept Vasc Med, Hamburg, Germany.
Show others and affiliations
2018 (English)In: European Journal of Vascular and Endovascular Surgery, ISSN 1078-5884, E-ISSN 1532-2165, Vol. 56, no 2, p. 181-188Article in journal (Refereed) Published
Abstract [en]

Objectives: Current management of ruptured abdominal aortic aneurysms (RAAA) varies among centres and countries, particularly in the degree of implementation of endovascular aneurysm repair (EVAR) and levels of vascular surgery centralisation. This study assesses these variations and the impact they have on outcomes.

Materials and methods: RAAA repairs from vascular surgical registries in 11 countries, 2010-2013, were investigated. Data were analysed overall, per country, per treatment modality (EVAR or open aortic repair [OAR]), centre volume (quintiles IV), and whether centres were predominantly EVAR (>= 50% of RAAA performed with EVAR [EVAR(p)]) or predominantly OAR [OAR(p)]. Primary outcome was peri-operative mortality. Data are presented as either mean values or percentages with 95% CI within parentheses, and compared with chi-square tests, as well as with adjusted OR.

Results: There were 9273 patients included. Mean age was 74.7 (74.5-74.9) years, and 82.7% of patients were men (81.9-83.6). Mean AAA diameter at rupture was 7.6 cm (7.5-7.6). Of these aneurysms, 10.7% (10.0-11.4) were less than 5.5 cm. EVAR was performed in 23.1% (22.3-24.0). There were 6817 procedures performed in OAR(p) centres and 1217 performed in EVAR(p) centres. Overall peri-operative mortality was 28.8% (27.9-29.8). Peri-operative mortality for OAR was 32.1% (31.0-33.2) and for EVAR 17.9% (16.3-19.6), p < .001, and the adjusted OR was 0.38 (0.31-0.47), p < .001. The peri-operative mortality was 23.0% in EVAR(p) centres (20.6-25.4), 29.7% in OAR(p) centres (28.6-30.8), p < .001; adjusted OR = 0.60 (0.46-0.78), p < .001. Perioperative mortality was lower in the highest volume centres (QI > 22 repairs per year), 23.3% (21.2-25.4) than in QII-V, 30.0% (28.9-31.1), p < .001. Peri-operative mortality after OAR was lower in high volume centres compared with the other centres, 25.3% (23.0-27.6) and 34.0% (32.7-35.4), respectively, p < .001. There was no significant difference in peri-operative mortality after EVAR between centres based on volume.

Conclusions: Peri-operative mortality is lower in centres with a primary EVAR approach or with high case volume. Most repairs, however, are still performed in low volume centres and in centres with a primary OAR strategy. Reorganisation of acute vascular surgical services may improve outcomes of RAAA repair.

Place, publisher, year, edition, pages
W B SAUNDERS CO LTD , 2018. Vol. 56, no 2, p. 181-188
Keywords [en]
Aortic aneurysm, Abdominal, Aortic rupture, Stent grafts, Quality and outcomes
National Category
Surgery
Identifiers
URN: urn:nbn:se:uu:diva-365834DOI: 10.1016/j.ejvs.2018.01.014ISI: 000444272200008PubMedID: 29482972OAI: oai:DiVA.org:uu-365834DiVA, id: diva2:1265784
Available from: 2018-11-26 Created: 2018-11-26 Last updated: 2019-11-23
In thesis
1. On Surgical Treatment of Aortic Pathology
Open this publication in new window or tab >>On Surgical Treatment of Aortic Pathology
2019 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The use of endovascular aneurysm repair (EVAR) in the treatment of abdominal aortic aneurysms has advanced from a premature characterization as a “failed experiment” in early 2000 to the predominant modern method of treatment. Technology has accommodated initial shortcomings, but it has also led to expansions in the treatment of ruptured aneurysms and complex aortic pathologies. The overall aim of this thesis is to characterize the contemporary utilization of endovascular repair in the international setting and to evaluate its expanding use in complex aortic disease treatment.

Paper I is an analysis of outcomes after intact aneurysm treatment from registries of 12 countries. From 2005 to 2013, and with 83,253 patients included, it was shown that the use of EVAR has increased while, the perioperative mortality has decreased. This was counterbalanced by a worsening mortality for those patients treated with open aortic repair.

Paper II is an analysis of ruptured aneurysms from the above-mentioned international registries. EVAR is also increasing for these patients, although open repair is still the predominant treatment strategy in most centres. Perioperative mortality was superior for EVAR patients, despite increased age and comorbidities. An association between patient-volume and perioperative mortality could be shown for open repair, but the same could not be demonstrated for EVAR.

Paper III is an evaluation of the adaptation of a total endovascular approach for the treatment of complex abdominal aortic aneurysms from a single centre. The technical success and midterm mortality, as well as post-operative complications, including spinal ischemia, were similar to those reported from large and multi-centre analyses. Previous studies reveal disparate results for centres performing open complex aortic repair. The results here suggest that a total endovascular approach is feasible for dedicated centres contemplating this strategy.  

Paper IV is an analysis of multiple pre-, peri-, and post-operative variables documented from complex aneurysm procedures. A relationship between increased complexity and variables such as anaesthesia duration, bleeding, hospital stay, and radiation exposure was found. As patients and their comorbidities increase, a decision to embark on a complex procedure should be made with due diligence to these relationships.

Paper V is a technical analysis of patients following acute treatment for Type A aortic dissections. Many patients are unfit for open aortic arch repair. Based on current availability of endovascular aortic stentgrafts, it was shown that the majority of patients can be treated endovascularly, while anticipated device improvements should further increase the proportion of eligibility. 

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2019. p. 61
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1613
Keywords
Abdominal aortic aneurysm, EVAR, F/BEVAR, aorta dissection.
National Category
Surgery
Identifiers
urn:nbn:se:uu:diva-395964 (URN)978-91-513-0806-7 (ISBN)
Public defence
2019-12-18, Rosénsalen, entrance 95/96, NBV, Akademiska sjukhuset, Uppsala, 13:00 (English)
Opponent
Supervisors
Available from: 2019-11-26 Created: 2019-10-28 Last updated: 2020-01-13

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