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Class 2 Advisor: Alberto Freitas

Introdução à Medicina II. Abdominal Aortic Aneurysm in Portuguese Mainland State Hospitals: Regional Variations of Treatment Choice and In-Hospital Mortality.

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Class 2 Advisor: Alberto Freitas

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  1. Introdução à Medicina II Abdominal Aortic Aneurysm in Portuguese Mainland State Hospitals: Regional Variations of Treatment Choice and In-Hospital Mortality Ana Catarina Rodrigues, Carolina Rodrigues, Catarina Cruz, Diogo Costa, Isabel Vazquez, Joana Garcia, Joana Rei, João Paulo Carvalho, José João Monteiro, José Pedro Vale, Lúcia Vieira, Manuel Neiva de Sousa, Marisa Martins and Ricardo Coutinho Class 2 Advisor: Alberto Freitas

  2. Table of Contents • Introduction • Background • Justification • Aims • Participants and Methods • Study participants • Study design • Data collection methods • Variable descriptions • Statistical analysis • Results • Conclusion and Discussion • References

  3. Table of Contents • Introduction • Background • Justification • Aims • Participants and Methods • Study participants • Study design • Data collection methods • Variable descriptions • Statistical analysis • Results • Conclusion and Discussion • References

  4. Background • Convention: an infrarenal aorta of 3 cm in diameter or larger is considered aneurysmal3 Aorta with large abdominal aneurysm Normal aorta 1 Upchurch (2006) Am Fam Physician, 73(7): 1198-204 2 Lederle (1997) J Vasc Surg, 26(4): 595-601 • Abdominal Aortic Aneurysm (AAA) • Permanent focal dilatation of the abdominal artery below the kidneys (infrarenal) to at least1,5 times its normal diameter1 • Normal values (above 50 years-old)2 • Men: 1,99 cm • Women: 1,66 cm 3 Johnston (1991) J Vasc Surg, 13(3): 452-8

  5. Background 1Berman (2008) J Vasc Surg, 47(2): 287-295 2 Egorova (2008) J Vasc Surg, 48(5): 1092-100 3 Katz (1997) J Vasc Surg, 25(3): 561-8 4 Lederle (1999) JAMA, 281(1): 77-82 • Abdominal aortic aneurysm affects 1% of individuals over the age of 55 and increases in incidence by 2% to 4% per decade thereafter1 • Main risk factors: • Gender: • Men are 3 times more likely to develop this type of aneurysm than women2 • Men are 10 times more likely to have an aneurysm of this type of 4 cm or larger3 • Age • Incidence rapidly increases after age 55 in men / 70 in women4

  6. Background Performed in patients with high risk of post-operative complications 1 Prinssen (2004) N Engl J Med, 351(16): 1607-18 • Two major types of surgical interventions: • Open Repair (OR)1 • Endovascular Aneurysm Repair (EVAR) 2 2 Greenhalgh (2004) Lancet, 364(9437): 843-8

  7. Justification • Abdominal aortic aneurysm is one of the 10 major causes of death in men over 65 years of age in western countries.1 • It is important to learn how surgical interventions used and fatality vary in different regions • knowing which regions have better outcome for either EVAR or OR will allow us to conclude where the patient has best chances of survival • Comparing Portugal’s mortality rates with those of other countries will allow us to conclude whether it is better or worse to be submitted to this type of surgical intervention in Portugal • Portugal may serve as an example of either what to do or what not to do in regard to the surgical intervention chosen for treating an abdominal aortic aneurysm 1 Katz (1997) J Vasc Surg, 25(3): 561-8

  8. Aims • To analyse the baseline characteristics for patients undergoing endovascular or open abdominal aortic aneurysm repair in Portuguese mainland state hospitals during the studied period • To compare the choice of surgical approach (EVAR or OR) among the different regions; • To determine the most frequent type of abdominal aortic aneurysm (ruptured or non-ruptured) submitted to surgical intervention in Portuguese mainland state hospitals of each region; • To calculate and compare the in-hospital mortality associated: • with ruptured / non-ruptured aneurysms • with the different surgical approaches (OR and EVAR) • with the different regions

  9. Table of Contents • Introduction • Background • Justification • Aims • Participants and Methods • Study participants • Study design • Data collection methods • Variable descriptions • Statistical analysis • Results • Conclusion and Discussion • References

  10. Table of Contents • Introduction • Background • Justification • Aims • Participants and Methods • Study participants • Study design • Data collection methods • Variable descriptions • Statistical analysis • Results • Conclusion and Discussion • References

  11. Study participants • All Portuguese mainland state hospitals inpatients episodes • Diagnosed with ruptured/non-ruptured abdominal aortic aneurysm • Submitted to either OR or EVAR for these conditions • Database: • records from all Portuguese mainland state hospitals • period 2000-2009* * incomplete data (from Jan-Sep)

  12. Study design • Characterization of the population by: • Gender • Age • Yearly ratio ruptured/non-ruptured surgeries • Yearly ratio OR/EVAR • In-hospital mortality

  13. Data collection methods • Patient hospital episode administrative database using the DRG classification system ICD-9-CM codes used for patient selection Ruptured aneurysm Non-ruptured aneurysm Open repair (OR) Endovascular repair (EVAR)

  14. Variables description • Gender (raw data) • Age (raw data) • Type of Aneurysm (recoded variable) • ruptured vs. non-ruptured • Type of surgical intervention (recoded variable) • OR vs. EVAR • Mortality (raw data) • Location of mainland state hospital (recoded variable) • Division in 5 regions (Norte, Centro, Lisboa, Alentejo and Algarve) according to the NUTS II classification

  15. Statistical analysis

  16. Table of Contents • Introduction • Background • Justification • Aims • Participants and Methods • Study participants • Study design • Data collection methods • Variable descriptions • Statistical analysis • Results • Conclusion and Discussion • References

  17. Table of Contents • Introduction • Background • Justification • Aims • Participants and Methods • Study participants • Study design • Data collection methods • Variable descriptions • Statistical analysis • Results • Conclusion and Discussion • References

  18. Results 2474 repairs 200 excluded (date of surgery unregistered) n = 2274 28,85% Norte n = 656 15,35% Centro n = 349 54,92% Lisboa n = 1249 0,84% Alentejo n = 19 0,04% Algarve n = 1

  19. Results Baseline characteristics for patients undergoing endovascular or open abdominal aortic aneurysm repair in Portuguese mainland state hospitals during the studied period There are significant differences between the age of patients * Lack of cases impaired statistical analysis. **Calculated using the Kruskal-Wallis test for age and the Chi square test for male gender. Patients submitted to EVAR in Lisboa are older than those submitted to OR in Norte, Centro and Lisboa (determined using Mann-Whitney U paired test and Holm-Bonferroni adjustment) There are no significant differences between the gender of patients

  20. Yearly distribution of total Abdominal aortic aneurysm repairs according to surgical intervention

  21. Yearly distribution of total Abdominal aortic aneurysm repairs according to surgical intervention OR was the preferred method from 2000-2009 EVAR is increasing since 2005

  22. Results Yearly percentage of endovascular aneurysm repair in total abdominal aortic aneurysm surgical interventions in Portuguese mainland state hospitals

  23. Yearly distribution of total abdominal aortic aneurysm (AAA) surgical interventions according to aneurysm type The ratio Non-ruptured/Ruptured AAA is approximately 3/1

  24. Results Yearly percentage of non-ruptured aneurysm repairs in total abdominal aortic aneurysms surgical interventions in Portuguese mainland state hospitals

  25. Results Regional distribution of in-hospital mortality according to type of abdominal aortic aneurysm and repair procedure No significant differences on mortality were found between OR and EVAR *Calculated using the Fisher’s exact test. **Calculated using the Chi square test. ***Lack of cases impaired statistical analysis. Tendency for EVAR to present better outcome in non-ruptured AAAs Tendency for OR to present better outcome in ruptured AAAs

  26. Table of Contents • Introduction • Background • Justification • Aims • Participants and Methods • Study participants • Study design • Data collection methods • Variable descriptions • Statistical analysis • Results • Conclusion and Discussion • References

  27. Table of Contents • Introduction • Background • Justification • Aims • Participants and Methods • Study participants • Study design • Data collection methods • Variable descriptions • Statistical analysis • Results • Conclusion and Discussion • References

  28. Conclusions Gender/Age • Men were the most affected gender undergoing surgery (9 to 1) • AAAs 3 times more frequent in men • AAAs larger in men • Patients undergoing EVAR in Lisboa are significantly older than those undergoing OR in Norte, Centro and Lisboa • triage process where high-risk, older patients are selected for EVAR

  29. Conclusions Open Repair vs. Endovascular Aneurysm Repair • Increase in total number of surgeries • OR as the preferred surgical intervention • Increase in the use of EVAR

  30. Conclusions Open Repair vs. Endovascular Aneurysm Repair • EVAR may present better outcome in non-ruptured aneurysms (not confirmed by statistical analysis) • EVAR in ruptured aneurysm seemingly increases in-hospital mortality • only performed as last resort, on patients where survival odds are already low

  31. Conclusions Ruptured aneurysm vs. non-ruptured aneurysm • Most surgical interventions performed on non ruptured aneurysm • most patients with ruptured aneurysm don’t reach hospital alive • Elective surgery presents low in-hospital mortality • Treating an aneurysm prior to its rupture is the main factor for achieving lower mortality rates

  32. Prior published in-hospital and 30-day mortalities following treatment of ruptured and non-ruptured abdominal aortic aneurysms

  33. Conclusions In-hospital mortality rates • Higher than those of other Western countries • Exception: Norte

  34. Conclusions Limitations • Low number of patients undergoing EVAR could explain high p values obtained, impairing statistical confirmation of the EVAR better outcome, especially in Norte • The cause of death of patients with ruptured abdominal aortic aneurysm is often attributed to other pathologies – numbers may be underestimated • Surgeons’ personal testimonies refer the use of EVAR since the beginning of the decade – directly contradicts the data • Flawed insertion of the ICD-9-CM codes on database • Lack of specific training for using the software • Complex procedures to registry data

  35. Table of Contents • Introduction • Background • Justification • Aims • Participants and Methods • Study participants • Study design • Data collection methods • Variable descriptions • Statistical analysis • Results • Conclusion and Discussion • References

  36. Table of Contents • Introduction • Background • Justification • Aims • Participants and Methods • Study participants • Study design • Data collection methods • Variable descriptions • Statistical analysis • Results • Conclusion and Discussion • References

  37. References • 1998. Mortality results for randomised controlled trial of early elective surgery or ultrasonographic surveillance for small abdominal aortic aneurysms. The UK Small Aneurysm Trial Participants.Lancet, 352(9141): 1649-55. • Acosta S, Lindblad B, and Zdanowski Z, 2007. Predictors for outcome after open and endovascular repair of ruptured abdominal aortic aneurysms.Eur J Vasc Endovasc Surg, 33(3): 277-84. • Arko F R, Lee W A, Hill B B, Olcott C t, Dalman R L, Harris E J, Jr., Cipriano P, Fogarty T J, and Zarins C K, 2002. Aneurysm-related death: primary endpoint analysis for comparison of open and endovascular repair.J Vasc Surg, 36(2): 297-304. • Berman L, Dardik A, Bradley E H, Gusberg R J, and Fraenkel L, 2008. Informed consent for abdominal aortic aneurysm repair: assessing variations in surgeon opinion through a national survey.J Vasc Surg, 47(2): 287-295. • Egorova N, Giacovelli J, Greco G, Gelijns A, Kent C K, and McKinsey J F, 2008. National outcomes for the treatment of ruptured abdominal aortic aneurysm: comparison of open versus endovascular repairs.J Vasc Surg, 48(5): 1092-100, 1100 e1-2. • Garcia-Madrid C, Josa M, Riambau V, Mestres C A, Muntana J, and Mulet J, 2004. Endovascular versus open surgical repair of abdominal aortic aneurysm: a comparison of early and intermediate results in patients suitable for both techniques.Eur J Vasc Endovasc Surg, 28(4): 365-72. • Greco G, Egorova N, Anderson P L, Gelijns A, Moskowitz A, Nowygrod R, Arons R, McKinsey J, Morrissey N J, and Kent K C, 2006. Outcomes of endovascular treatment of ruptured abdominal aortic aneurysms.J Vasc Surg, 43(3): 453-459. • Greenhalgh R M, Brown L C, Kwong G P, Powell J T, and Thompson S G, 2004. Comparison of endovascular aneurysm repair with open repair in patients with abdominal aortic aneurysm (EVAR trial 1), 30-day operative mortality results: randomised controlled trial.Lancet, 364(9437): 843-8. • Holm S, 1979. A simple sequential rejective multiple test procedure.Scandinavian Journal of Statistics, 6: 65-70. • Johnston K W, Rutherford R B, Tilson M D, Shah D M, Hollier L, and Stanley J C, 1991. Suggested standards for reporting on arterial aneurysms. Subcommittee on Reporting Standards for Arterial Aneurysms, Ad Hoc Committee on Reporting Standards, Society for Vascular Surgery and North American Chapter, International Society for Cardiovascular Surgery.J Vasc Surg, 13(3): 452-8. • Katz D J, Stanley J C, and Zelenock G B, 1997. Gender differences in abdominal aortic aneurysm prevalence, treatment, and outcome.J Vasc Surg, 25(3): 561-8. • Lederle F A and Simel D L, 1999. The rational clinical examination. Does this patient have abdominal aortic aneurysm? JAMA, 281(1): 77-82.

  38. References • Lederle F A, Freischlag J A, Kyriakides T C, Padberg F T, Jr., Matsumura J S, Kohler T R, Lin P H, Jean-Claude J M, Cikrit D F, Swanson K M, and Peduzzi P N, 2009. Outcomes following endovascular vs open repair of abdominal aortic aneurysm: a randomized trial.JAMA, 302(14): 1535-42. • Lederle F A, Johnson G R, Wilson S E, Gordon I L, Chute E P, Littooy F N, Krupski W C, Bandyk D, Barone G W, Graham L M, Hye R J, and Reinke D B, 1997. Relationship of age, gender, race, and body size to infrarenal aortic diameter. The Aneurysm Detection and Management (ADAM) Veterans Affairs Cooperative Study Investigators.J Vasc Surg, 26(4): 595-601. • Lederle F A, Wilson S E, Johnson G R, Reinke D B, Littooy F N, Acher C W, Ballard D J, Messina L M, Gordon I L, Chute E P, Krupski W C, Busuttil S J, Barone G W, Sparks S, Graham L M, Rapp J H, Makaroun M S, Moneta G L, Cambria R A, Makhoul R G, Eton D, Ansel H J, Freischlag J A, and Bandyk D, 2002. Immediate repair compared with surveillance of small abdominal aortic aneurysms.N Engl J Med, 346(19): 1437-44. • Leon L R, Jr., Labropoulos N, Laredo J, Rodriguez H E, and Kalman P G, 2005. To what extent has endovascular aneurysm repair influenced abdominal aortic aneurysm management in the state of Illinois? J Vasc Surg, 41(4): 568-74. • McPhee J T, Hill J S, and Eslami M H, 2007. The impact of gender on presentation, therapy, and mortality of abdominal aortic aneurysm in the United States, 2001-2004.J Vasc Surg, 45(5): 891-9. • Monge M and Eskandari M K, 2008. Strategies for ruptured abdominal aortic aneurysms.J Vasc Interv Radiol, 19(6 Suppl): S44-50. • Prinssen M, Verhoeven E L, Buth J, Cuypers P W, van Sambeek M R, Balm R, Buskens E, Grobbee D E, and Blankensteijn J D, 2004. A randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms.N Engl J Med, 351(16): 1607-18. • Rayt H S, Sutton A J, London N J, Sayers R D, and Bown M J, 2008. A systematic review and meta-analysis of endovascular repair (EVAR) for ruptured abdominal aortic aneurysm.Eur J Vasc Endovasc Surg, 36(5): 536-44. • Sadat U, Boyle J R, Walsh S R, Tang T, Varty K, and Hayes P D, 2008. Endovascular vs open repair of acute abdominal aortic aneurysms--a systematic review and meta-analysis.J Vasc Surg, 48(1): 227-36. • Schermerhorn M L, O'Malley A J, Jhaveri A, Cotterill P, Pomposelli F, and Landon B E, 2008. Endovascular vs. open repair of abdominal aortic aneurysms in the Medicare population.N Engl J Med, 358(5): 464-74.

  39. References • Sharif M A, Lee B, Makar R R, Loan W, and Soong C V, 2007. Role of the Hardman index in predicting mortality for open and endovascular repair of ruptured abdominal aortic aneurysm.J EndovascTher, 14(4): 528-35. • Starnes B W, Quiroga E, Hutter C, Tran N T, Hatsukami T, Meissner M, Tang G, and Kohler T, 2010. Management of ruptured abdominal aortic aneurysm in the endovascular era.J VascSurg, 51(1): 9-17; discussion 17-8. • Sullivan C A, Rohrer M J, and Cutler B S, 1990. Clinical management of the symptomatic but unruptured abdominal aortic aneurysm.J VascSurg, 11(6): 799-803. • Upchurch G R, Jr. and Schaub T A, 2006. Abdominal aortic aneurysm.Am Fam Physician, 73(7): 1198-204. • Visser J J, Williams M, Kievit J, and Bosch J L, 2009. Prediction of 30-day mortality after endovascular repair or open surgery in patients with ruptured abdominal aortic aneurysms.J Vasc Surg, 49(5): 1093-9. • Vogel T R, Dombrovskiy V Y, Haser P B, and Graham A M, 2009. Has the implementation of EVAR for ruptured AAA improved outcomes? Vasc Endovascular Surg, 43(3): 252-7. • Wakefield T W, Whitehouse W M, Jr., Wu S C, Zelenock G B, Cronenwett J L, Erlandson E E, Kraft R O, Lindenauer S M, and Stanley J C, 1982. Abdominal aortic aneurysm rupture: statistical analysis of factors affecting outcome of surgical treatment.Surgery, 91(5): 586-96. • Wanhainen A, Bylund N, and Bjorck M, 2008. Outcome after abdominal aortic aneurysm repair in Sweden 1994-2005.Br J Surg, 95(5): 564-70. • Wahlgren C M and Malmstedt J, 2008. Outcomes of endovascular abdominal aortic aneurysm repair compared with open surgical repair in high-risk patients: results from the Swedish Vascular Registry.J VascSurg, 48(6): 1382-8; discussion 1388-9.

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