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Class 5 1 st Year Mestrado Integrado em Medicina

The Influence of Risk Factors on Mortality Rates after Elective Open Repair of Abdominal Aortic Aneurysms (AAA). Class 5 1 st Year Mestrado Integrado em Medicina. Abdominal Aortic Aneurysm (AAA).

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Class 5 1 st Year Mestrado Integrado em Medicina

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  1. The Influence of Risk Factors on Mortality Rates after Elective Open Repair of Abdominal Aortic Aneurysms (AAA) Class 51st Year Mestrado Integrado em Medicina

  2. Abdominal Aortic Aneurysm (AAA) • Abnormal widening of abdominal aorta below the renal arteries (at least 1.5-folds the normal diameter); • 13th cause of death in the United States (US): • 200,000 new diagnosis each year; • 40,000 surgical repairs each year; • 15,000 die from rupture each year. • 3rd cause of sudden death in men >60 in US; • 75% are asymptomatic until their rupture. Introduction

  3. Risk Factors for AAA • Age>50 y.o. and male gender • Hypertension • Atherosclerosis • Chronic obstructive pulmonary disease • Smoking • Family history of AAA • Previous vascular surgery Introduction

  4. Elective Open Repair (EOR) of AAA • Established procedure for patients >40 years • Invasive surgery procedure with insertion of a prosthetic tube-like graft • Excludes aneurysm and prevents growth • Proven, long-term results • Considered the “gold standard” • Operative mortality rounds 1% to 5% Introduction

  5. Elective Open Repair (EOR) of AAA Petr Utikala (2004), Biomed Papers 148(2), 183–187 Introduction

  6. Postoperative Complications of EOR • Venous Bleeding/Haemorrhage • Gastrointestinal ischemia and/or dysfunction • Cardiac events (including Myocardial Infarction) • Pulmonary insufficiency • Organ Failure • Renal failure • Graft infection Introduction

  7. Research Question and Aims Research Questions: • Which risk factors mostly contribute to mortality after EOR? • Is it possible to improve the prediction of patients’ outcome after EOR? Aims: • Develop a meta-analysis review; • Summarize the risk factors, postoperative complications and mortality rates of patients with AAA undergoing EOR; • Analyze the influence of risk factors on patients’ outcome after EOR; • Contribute to the improvement of the prediction of patients’ outcome. Research Question and Aims

  8. Participants and Methods Participants and Methods

  9. Type of Study Meta-Analysis Review Participants and Methods

  10. Study Participants All articles (n=203) published on PubMed Database considering: • "abdominal aortic aneurysm"[Text Word] OR "aortic aneurysm, abdominal"[MeSH Terms] OR aaa[Text Word] • AND elective[All Fields] • AND open[All Fields] • AND ((("wound healing"[TIAB] NOT Medline[SB]) OR "wound healing“[MeSH Terms] OR repair[Text Word]) OR ("surgery"[Subheading] OR "operative surgical procedures"[Text Word] OR "surgical procedures, operative"[MeSH Terms] OR "surgery"[MeSH Terms] OR surgery[Text Word])) • AND mortality[Text Word] Participants and Methods

  11. Study Design: 1st Triage Step Inclusion Criteria • Abdominal aortic aneurysms (AAA) • Elective open repair/surgery (EOR) • Mortality rates after elective open repair • Postoperative complications • Patient’s outcome Exclusion Criteria • Other types or “mixed” aortic aneurysms (n=10) • Emergency repair of ruptured AAA (n=13) • Patients submitted to endovascular repair (EVAR) (n=51) • Other papers as reviews, systematic reviews, meta-analysis, letters or editorials (n=20) • Papers in other languages rather than English, French, Spanish or Portuguese (n=16) • Not related studies (n=26) Participants and Methods

  12. Study Design: 1st Triage Step Participants and Methods

  13. Study Design: 2nd Triage Step Inclusion Criteria • Full paper available • Provide data about preoperative clinical variables and risk factors • Provide data about postoperative complications • Provide data about patients’ mortality/outcome Exclusion Criteria • Impossibility to obtain full article by on line request, library acquisition or e-mail request to authors (n=13) • Other types of articles such as, review (n=1) or meeting abstract (n=1) • Not related to the study (n=5) • Absence of data about risk factors (n=10) • Absence of data about mortality (n=4) • Absence of data combining mortality associated to risk factors (n=29) Participants and Methods

  14. Study Design: 2nd Triage Step Participants and Methods

  15. Selected Variables • Study characteristics • Name of first Author, Year of Publication • Type of Study • Country of Origin • Sample Size (n) • Preoperative clinical variables • Age (mean) • Aneurysm Diameter (mean) • Gender (male and female %) • Risk Factors exposition • Diabetes Mellitus, DM (%) • History of Cardiac Disease, CDH (%) – History of myocardial infarction and/or angina • Hypertension, HT (%) • History of Pulmonary Disease, PDH (%) – History of COPD or pulmonary embolism • Chronic Renal Failure, CRF (%) – Creatinine levels (>2.0mg/dL) • Smoking Habits (%) Participants and Methods

  16. Selected Variables • Postoperative Complications • Morbidity Events, (%) • Venous Bleeding, (%) • Gastrointestinal Ischemia, GIsch (%) • MultiOrgan Failure, MOF (%) • Renal Failure, RF (%) • Cardiac Complications, CardiacC (%) • Myocardial Infarction, MI (%) • Respiratory Complications, RespC (%) • Patients Outcome • Mortality (%) • Statistical Data • Risk factor associated Odds Ratio • Risk factor associated Confidence Interval Participants and Methods

  17. Statistical Analysis • Data input on Database using Statistical Package for Social Sciences (SPSS) Version 16.0 used to summarize the mean frequencies, confidence intervals and standard deviations of all clinical variables, risk factors exposition, postoperative complications, and mortality rates; • Epi Info™, Version 6 to perform a χ2 analysis to determine the Odds Ratio (OR) and 95% confidence interval for the association of risk factors influence on patients’ outcome; • R Version 2.6.2 to elaborate the Forest Plot graphics in order to combine the information about the influence of risk factors on patients’ outcome. Participants and Methods

  18. Systematic Review Meta-Analysis Results Summarize risk factors and postoperative complications, as well as the mortality rate within all studies. Determine the Odds Ratio (OR) and 95% confidence interval for the influence of risk factors on patients’ outcome and elaborate the Forest Plots in order to combine the information from all studies. Results

  19. Systematic Review • Combine data from 46 articles (29 + 17) which result in 50 individual studies regarding the frequencies of: • Risk Factors • Postoperative complications • Morbidity rates • Mortality rates Results

  20. Systematic Review Results

  21. Systematic Review • Summary • Median % of Male Gender is 86.9% • Median % of patients with HT is 60.0% • Median % of patients with Smoking habits is 54.2% • Median % of patients with CDH is 44.3% • Median % of Cardiac Complications is 5.7% • Median % of Respiratory Complications is 7.5% • Median occurrence of Morbidity events of 31.0% • Median frequency of Mortality was 4.0% Results

  22. Meta-Analysis • Combine data regarding the influence of risk factors on patients’ outcome: • Mean Age (y.o.) • Mean Aneurysm Diameter (cm) • Gender • Diabetes Mellitus, DM • History of Cardiac Disease, CDH • Hypertension, HT • History of Pulmonary Disease, PDH • Chronic Renal Failure, CRF • Smoking Habits Results

  23. Meta-Analysis Mean Age Test of heterogeneity: Q: 21,35 d.f.: 7 p.value: 0,003 OR=1.07 95% CI (1.05 – 1.09) p<0.001 0.5 2.0 1.0 5.0 10.0 Results

  24. Meta-Analysis Mean Aneurysm Diameter Test of heterogeneity: Q: 0,19 d.f.: 2 p.value: 0,910 OR=1.58 95% CI (1.11 – 2.25) p=0.011 1.0 0.5 2.0 Results

  25. Meta-Analysis Female Gender • Test of heterogeneity Q: 4,87 d.f.: 7 p.value: 0,676 OR=1.58 95% CI (1.39 – 1.80) p<0.001 1.0 0.2 0.5 2.0 5.0 10.0 20.0 Results

  26. Meta-Analysis Diabetes Mellitus • Test of heterogeneity Q: 1,24 d.f.: 3 p.value: 0,744 OR=1.28 95% CI (0.80 – 2.06) p=0.309 0.5 2.0 20.0 1.0 5.0 10.0 Results

  27. Meta-Analysis Cardiac Disease History (CDH) • Test of heterogeneity Q: 20 d.f.: 6 p.value: 0,003 OR=1.93 95% CI (1.42 – 2.62) p<0.001 0.05 0.1 1.0 50.0 0.2 0.5 2.0 5.0 20.0 Results

  28. Meta-Analysis Hypertension (HT) • Test of heterogeneity Q: 51,04 d.f.: 5 p.value: <0,001 OR=2.95 95% CI (2.14 – 4.05) p<0.001 0.05 0.1 1.0 50.0 0.2 0.5 2.0 5.0 10.0 20.0 Results

  29. Meta-Analysis Pulmonary Disease History (PDH) • Test of heterogeneity Q: 6,26 d.f.: 6 p.value: 0,394 OR=1.32 95% CI (0.94 – 1.87) p=0.112 0.1 1.0 0.2 0.5 2.0 5.0 10.0 Results

  30. Meta-Analysis Chronic Renal Failure (CRF) • Test of heterogeneity Q: 9,29 d.f.: 7 p.value: 0,232 OR=2.78 95% CI (2.21 – 3.47) p<0.001 0.5 5.0 20.0 1.0 2.0 10.0 50.0 100.0 Results

  31. Meta-Analysis Smoking Habits • Test of heterogeneity Q: 4,29 d.f.: 4 p.value: 0,368 OR=1.00 95% CI (0.99 – 1.01) p=0.987 0.05 2.0 0.5 0.1 0.2 1.0 5.0 Results

  32. Meta-Analysis • Resuming the influence of risk factor in patient’s outcome after EOR • Hypertension (OR=2.95; p<0.001) • Chronic Renal Failure (OR=2.78; p<0.001) • Cardiac Disease History (OR=1.93; p<0.001) • Female Gender (OR=1.58; p<0.001) • Aneurysm Diameter (OR=1.58; p=0.011) • Pulmonary Disease History (OR=1.32; p=0.112) • Diabetes Mellitus (OR=1.28; p=0.309) • Mean Age (OR=1.07; p<0.001) • Smoking (OR=1.00; p=0.987) Results

  33. Limits of the Study • Related to study design: • Search only in ONE online Database (PubMed). • Related to the query: • Absence of a unique MeSh term to define “elective open repair”; • The “huge” number of risk factors and postoperative complications; • Difficulty to define the outcome as <30 days after surgery. • Related to studies: • Heterogeneity of the studies; • Absence of data relative to the most common risk factors; • Absence of data relative to risk factors associated outcome. Discussion

  34. Discussion of Results Epidemiological Data Systematic review revealed: • Increased frequency of Male Gender (median 86.9%); • Patients are diagnosed with advanced age (mean 71.4 y.o); • Increased Aneurism Diameter (mean 5.9 cm); Our results show similar distribution to those shown in literature referring that AAA are more common in men with age ranging 65-75 y.o. and diagnosed with a diameter of the aorta below the renal arteries of >3.0 cm. Gillum RF. J ClinEpidemiol. 1995 Nov;48(11):1289-98.Flemming C, et al. Ann. Intern. Med. 142 (3): 203-11. Lederle FA, et al. Arch Intern Med. 2000;160:1425-30. Discussion

  35. Discussion of Results Risk Factors The most common risk factors found were: • Male Gender (median 86.9%); • Advanced age (mean 71.4 y.o); • History of Hypertension, HT (median 60.0%) • Smoking Habits (median 54.2%) • History of Cardiac Diseases, CDH (median 44.3%) The great majority of studies, including the “ACC/AHA 2005 guidelines”refer age, smoking, and gender as the most significant AAA risk factors, although, hypertension and history of cardiac disease are also consideredLederle FA, et al. Arch Intern Med. 2000;160:1425-30. Hirsch AT, et al. J Am CollCardiol2006 Mar 21;47(6):1239-312 Discussion

  36. Discussion of Results Morbidity/Postoperative Complications The median occurrence of Morbidity events was of 31.0%, and the most frequent postoperative complications found were: • Respiratory Complications (median 7.5%) • Cardiac Complications (median 5.7%) There is a wide variety of postoperative complications, and most of them are correlated with the healthy condition of the patient prior to the surgery, or also to the experience of the surgical team. Nevertheless, it is accepted that between 5-25% of all patients will at least suffer one complication. Hirsch AT, et al. J Am CollCardiol2006 Mar 21;47(6):1239-312Wilt TJ, et al.Evid Rep Technol Assess (Full Rep). 2006 Aug;(144):1-113. Discussion

  37. Discussion of Results Mortality Rate The median frequency of Mortality found was 4.0%. Mortality rates <30days after surgery for patients undergoing EOR ranges between 1-5%, although in some surgical teams this can be 0%. Despite the differential conditions of patients, in-hospital care conditions are extremely important to prevent higher mortality rates. Hirsch AT, et al. J Am CollCardiol2006 Mar 21;47(6):1239-312 Moreover, mortality rates seem to be influenced by patients’ risk factor exposition and therefore can vary within studies. Lederle FA, et al. Arch Intern Med. 2000;160:1425-30. Discussion

  38. Discussion of Results Influence of risk factor in patient’s outcome after EOR Smoking is considered to represent a significant risk marker for AAA development, although, statistical analysis revealed that patient’s outcome was not influenced by Smoking Habits. Despite statistical analysis did not provide significant data, Pulmonary Disease History and Diabetes Mellitus may influence the outcome since they represent an increase of 32% and 28%, respectively, in the risk for death after EOR if present. Nevertheless, these two risk factors require more studies to clarify its effect on patients’ outcome. Discussion

  39. Discussion of Results Influence of risk factor in patient’s outcome after EOR Statistical analysis revealed that Hypertension or Chronic Renal Failure represent an almost 3-folds increased risk for death after EOR. These risk factors are strictly correlated with patients’ health condition and are extremely important in the recovery after any surgical procedure. As expected Cardiac Disease History represent an increased risk factor for death after EOR (almost 2-folds), since it is common that people who suffered cardiac events may have repetitions shortly in time. Discussion

  40. Discussion of Results Influence of risk factor in patient’s outcome after EOR Remarkably interesting is the fact that Female Gender revealed a 58% increase risk of death after EOR. Male gender represent a risk factor, however, when females develop AAA, usually it has more severe consequences and death can occur shortly after surgery. Statistical analysis also revealed that an increment of 1cm of the Aneurysm Diameter represents a 58% increase risk of death after EOR. Age has also proved to influence the risk of death after EOR, with an increment of 7% per year. Discussion

  41. Final Conclusions Despite the fact that EOR has been substituted by Endovascular Repair, EOR has proven to have good results in AAA management, but may require experienced surgeons and good in-hospital intensive care unites in order to contribute for the improvement of AAA management. Our study revealed important findings that contribute to the prediction of patient’s outcome after EOR, by simple analysis of risk factor exposition. Moreover, it may allow the development of a decision tree for the selection of patients that can be submitted to EOR and expect a good outcome. Discussion

  42. The Influence of Risk Factors on Mortality Rates after Elective Open Repair of Abdominal Aortic Aneurysms (AAA) Class 51st Year Mestrado Integrado em Medicina

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