N Lijftogt1, A C Vahl2, E G Karthaus1,3, E M van der Willik3, S Amodio4, E W van Zwet4, J F Hamming1. 1. Department of Vascular Surgery, Leiden University Medical Centre, Leiden, the Netherlands. 2. Department of Surgery and Clinical Epidemiology, OLVG, Amsterdam, the Netherlands. 3. Dutch Institute for Clinical Auditing, Leiden, the Netherlands. 4. Department of Medical Statistics, Leiden University Medical Centre, Leiden, the Netherlands.
Abstract
BACKGROUND: Increased use of endovascular aneurysm repair (EVAR) and reduced open surgical repair (OSR), has decreased postoperative mortality after elective repair of abdominal aortic aneurysms (AAAs). The choice between EVAR or OSR depends on aneurysm anatomy, and the experience and preference of the vascular surgeon, and therefore differs between hospitals. The aim of this study was to investigate the current mortality risk difference (RD) between EVAR and OSR, and the effect of hospital preference for EVAR on overall mortality. METHODS: Primary elective infrarenal or juxtarenal aneurysm repairs registered in the Dutch Surgical Aneurysm Audit (2013-2017) were analysed. First, mortality in hospitals with a higher preference for EVAR (high-EVAR group) was compared with that in hospitals with a lower EVAR preference (low-EVAR group), divided by the median percentage of EVAR. Second, the mortality RD between EVAR and OSR was determined by unadjusted and adjusted linear regression and propensity-score (PS) analysis and then by instrumental-variable (IV) analysis, adjusting for unobserved confounders; percentage EVAR by hospital was used as the IV. RESULTS: A total of 11 997 patients were included. The median hospital rate of EVAR was 76.6 per cent. The overall mortality RD between high- and low-EVAR hospitals was 0.1 (95 per cent -0.5 to 0.4) per cent. The OSR mortality rate was significantly higher among high-EVAR hospitals than low-EVAR hospitals: 7.3 versus 4.0 per cent (RD 3.3 (1.4 to 5.3) per cent). The EVAR mortality rate was also higher in high-EVAR hospitals: 0.9 versus 0.7 per cent (RD 0.2 (-0.0 to 0.6) per cent). The RD following unadjusted, adjusted, and PS analysis was 4.2 (3.7 to 4.8), 4.4 (3.8 to 5.0), and 4.7 (4.1 to 5.3) per cent in favour of EVAR over OSR. However, the RD after IV analysis was not significant: 1.3 (-0.9 to 3.6) per cent. CONCLUSION: Even though EVAR has a lower mortality rate than OSR, the overall effect is offset by the high mortality rate after OSR in hospitals with a strong focus on EVAR.
BACKGROUND: Increased use of endovascular aneurysm repair (EVAR) and reduced open surgical repair (OSR), has decreased postoperative mortality after elective repair of abdominal aortic aneurysms (AAAs). The choice between EVAR or OSR depends on aneurysm anatomy, and the experience and preference of the vascular surgeon, and therefore differs between hospitals. The aim of this study was to investigate the current mortality risk difference (RD) between EVAR and OSR, and the effect of hospital preference for EVAR on overall mortality. METHODS: Primary elective infrarenal or juxtarenal aneurysm repairs registered in the Dutch Surgical Aneurysm Audit (2013-2017) were analysed. First, mortality in hospitals with a higher preference for EVAR (high-EVAR group) was compared with that in hospitals with a lower EVAR preference (low-EVAR group), divided by the median percentage of EVAR. Second, the mortality RD between EVAR and OSR was determined by unadjusted and adjusted linear regression and propensity-score (PS) analysis and then by instrumental-variable (IV) analysis, adjusting for unobserved confounders; percentage EVAR by hospital was used as the IV. RESULTS: A total of 11 997 patients were included. The median hospital rate of EVAR was 76.6 per cent. The overall mortality RD between high- and low-EVAR hospitals was 0.1 (95 per cent -0.5 to 0.4) per cent. The OSR mortality rate was significantly higher among high-EVAR hospitals than low-EVAR hospitals: 7.3 versus 4.0 per cent (RD 3.3 (1.4 to 5.3) per cent). The EVAR mortality rate was also higher in high-EVAR hospitals: 0.9 versus 0.7 per cent (RD 0.2 (-0.0 to 0.6) per cent). The RD following unadjusted, adjusted, and PS analysis was 4.2 (3.7 to 4.8), 4.4 (3.8 to 5.0), and 4.7 (4.1 to 5.3) per cent in favour of EVAR over OSR. However, the RD after IV analysis was not significant: 1.3 (-0.9 to 3.6) per cent. CONCLUSION: Even though EVAR has a lower mortality rate than OSR, the overall effect is offset by the high mortality rate after OSR in hospitals with a strong focus on EVAR.
Authors: Hector W L de Beaufort; Elena Cellitti; Quirina M B de Ruiter; Michele Conti; Santi Trimarchi; Frans L Moll; Constantijn E V B Hazenberg; Joost A van Herwaarden Journal: J Vasc Surg Date: 2017-06-28 Impact factor: 4.268
Authors: Vincent Jongkind; Kak K Yeung; George J M Akkersdijk; David Heidsieck; Johannes B Reitsma; Geert Jan Tangelder; Willem Wisselink Journal: J Vasc Surg Date: 2010-04-10 Impact factor: 4.268
Authors: N Lijftogt; A C Vahl; E D Wilschut; B H P Elsman; S Amodio; E W van Zwet; V J Leijdekkers; M W J M Wouters; J F Hamming Journal: Eur J Vasc Endovasc Surg Date: 2017-02-28 Impact factor: 7.069
Authors: J Budtz-Lilly; M Venermo; S Debus; C-A Behrendt; M Altreuther; B Beiles; Z Szeberin; N Eldrup; G Danielsson; I Thomson; P Wigger; M Björck; I Loftus; K Mani Journal: Eur J Vasc Endovasc Surg Date: 2017-04-13 Impact factor: 7.069
Authors: Neal R Barshes; James McPhee; C Keith Ozaki; Louis L Nguyen; Matthew T Menard; Edwin Gravereaux; Michael Belkin Journal: Ann Vasc Surg Date: 2012-01 Impact factor: 1.466
Authors: Monique Prinssen; Eric L G Verhoeven; Jaap Buth; Philippe W M Cuypers; Marc R H M van Sambeek; Ron Balm; Erik Buskens; Diederick E Grobbee; Jan D Blankensteijn Journal: N Engl J Med Date: 2004-10-14 Impact factor: 91.245
Authors: J T Powell; M J Sweeting; P Ulug; J D Blankensteijn; F A Lederle; J-P Becquemin; R M Greenhalgh Journal: Br J Surg Date: 2017-02 Impact factor: 6.939
Authors: A Karthikesalingam; M J Grima; P J Holt; A Vidal-Diez; M M Thompson; A Wanhainen; M Bjorck; K Mani Journal: Br J Surg Date: 2018-02-22 Impact factor: 6.939