Impact of vascular surgery on community mortality from ruptured aortic aneurysms

Ingoldby, C. J. H.; Wujanto, R.; Mitchell, Judith E.

doi:10.1002/bjs.1800730711

Cited by 199 publications

(51 citation statements)

References 11 publications

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“…49 The in-hospital survival rate for treating a ruptured aneurysm is just above 50%, but many patients never have the opportunity to undergo surgical intervention. 21 As the condition is not always found early, population screening programmes have been set up.…”

Section: Detection and Screeningmentioning

confidence: 99%

The UK EndoVascular Aneurysm Repair (EVAR) randomised controlled trials: long-term follow-up and cost-effectiveness analysis

Patel

Powell

Sweeting

et al. 2018

Health Technol Assess

103

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BackgroundShort-term survival benefits of endovascular aneurysm repair (EVAR) compared with open repair (OR) of intact abdominal aortic aneurysms have been shown in randomised trials, but this early survival benefit is soon lost. Survival benefit of EVAR was unclear at follow-up to 10 years.ObjectiveTo assess the long-term efficacy of EVAR against OR in patients deemed fit and suitable for both procedures (EVAR trial 1; EVAR-1); and against no intervention in patients unfit for OR (EVAR trial 2; EVAR-2). To appraise the long-term significance of type II endoleak and define criteria for intervention.DesignTwo national, multicentre randomised controlled trials: EVAR-1 and EVAR-2.SettingPatients were recruited from 37 hospitals in the UK between 1 September 1999 and 31 August 2004.ParticipantsMen and women aged ≥ 60 years with an aneurysm of ≥ 5.5 cm (as identified by computed tomography scanning), anatomically suitable and fit for OR were randomly assigned 1 : 1 to either EVAR (n = 626) or OR (n = 626) in EVAR-1 using computer-generated sequences at the trial hub. Patients considered unfit were randomly assigned to EVAR (n = 197) or no intervention (n = 207) in EVAR-2. There was no blinding.InterventionsEVAR, OR or no intervention.Main outcome measuresThe primary end points were total and aneurysm-related mortality until mid-2015 for both trials. Secondary outcomes for EVAR-1 were reinterventions, costs and cost-effectiveness.ResultsIn EVAR-1, over a mean of 12.7 years (standard deviation 1.5 years; maximum 15.8 years), we recorded 9.3 deaths per 100 person-years in the EVAR group and 8.9 deaths per 100 person-years in the OR group [adjusted hazard ratio (HR) 1.11, 95% confidence interval (CI) 0.97 to 1.27;p = 0.14]. At 0–6 months after randomisation, patients in the EVAR group had a lower mortality (adjusted HR 0.61, 95% CI 0.37 to 1.02 for total mortality; HR 0.47, 95% CI 0.23 to 0.93 for aneurysm-related mortality;p = 0.031), but beyond 8 years of follow-up patients in the OR group had a significantly lower mortality (adjusted HR 1.25, 95% CI 1.00 to 1.56,p = 0.048 for total mortality; HR 5.82, 95% CI 1.64 to 20.65,p = 0.0064 for aneurysm-related mortality). The increased aneurysm-related mortality in the EVAR group after 8 years was mainly attributable to secondary aneurysm sac rupture, with increased cancer mortality also observed in the EVAR group. Overall, aneurysm reintervention rates were higher in the EVAR group than in the OR group, 4.1 and 1.7 per 100 person-years, respectively (p < 0.001), with reinterventions occurring throughout follow-up. The mean difference in costs over 14 years was £3798 (95% CI £2338 to £5258). Economic modelling based on the outcomes of the EVAR-1 trial showed that the cost per quality-adjusted life-year gained over the patient’s lifetime exceeds conventional thresholds used in the UK. In EVAR-2, patients died at the same rate in both groups, but there was suggestion of lower aneurysm mortality in those who actually underwent EVAR. Type II endoleak itself is not associated with a higher rate of mortality.LimitationsDevices used were implanted between 1999 and 2004. Newer devices might have better results. Later follow-up imaging declined, particularly for OR patients. Methodology to capture reinterventions changed mainly to record linkage through the Hospital Episode Statistics administrative data set from 2009.ConclusionsEVAR has an early survival benefit but an inferior late survival benefit compared with OR, which needs to be addressed by lifelong surveillance of EVAR and reintervention if necessary. EVAR does not prolong life in patients unfit for OR. Type II endoleak alone is relatively benign.Future workTo find easier ways to monitor sac expansion to trigger timely reintervention.Trial registrationCurrent Controlled Trials ISRCTN55703451.FundingThis project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and the results will be published in full inHealth Technology Assessment; Vol. 22, No. 5. See the NIHR Journals Library website for further project information.

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Section: Detection and Screeningmentioning

confidence: 99%

The UK EndoVascular Aneurysm Repair (EVAR) randomised controlled trials: long-term follow-up and cost-effectiveness analysis

Patel

Powell

Sweeting

et al. 2018

Health Technol Assess

103

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“…In 1991 alone there were 4370 male deaths ascribed to AAA (International Classification of Diseases (ICD) code 441. [3][4][5][6]. One-third of patients with ruptured aneurysm die outside h~s p i t a l~.~.…”

mentioning

confidence: 99%

Influence of screening on the incidence of ruptured abdominal aortic aneurysm: 5-year results of a randomized controlled study

Scott

Wilson

Ashton

et al. 1995

Journal of British Surgery

428

277

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From family medical practices 15775 men and women of men). Aortic surgery was offered to the screened group aged 65-80 years were identified and randomized into two if certain criteria were met and no patient died from groups: one group was invited for ultrasonographic rupture who was fit for operation and accepted elective screening for abdominal aortic aneurysm (AAA), and the treatment. The incidence of rupture was reduced by 55 other acted as age-and sex-matched controls. Of the 7887 per cent in men in the group invited for screening, invited for screening 5394 (68.4 per cent) accepted. AAA compared with controls. The incidence of rupture in was detected in 218 (4.0 per cent overall and 7-6 per cent women was low in both groups. Patients and methodsMen and women aged 65-80 years were identified for each general practice in this district from a combination of the practice register and Family Health Service lists. The patients in each practice were then randomized by computer to 'control' and 'screening' groups. Patients randomized to screening were invited for abdominal ultrasonographic scanning by letter from their family practice; one reminder was sent if there was no reply. Maximum aortic diameter in the anteroposterior and transverse planes was measured as previously described". A diameter of 3 cm or more was considered aneurysmal. Patients with an aneurysm of 3.0-4.4 cm diameter were rescanned annually and those with an aneurysm of 45-59 cm diameter were rescanned at intervals of 3 months. This protocol was continued for the duration of the study to February 1994 or until the patient either died, underwent surgical intervention or declined further followup. The criteria for considering surgical repair were applied prospectively: an aortic diameter of 6 cm or more, an increase of diameter of 1 cm or more per year, or the development of symptoms attributable to the aneurysm. Abnormal scans and batches of normal scans were reviewed by a consultant radiologist for quality control. Patients were assessed in outpatient clinics at their third scan or if an abnormality was detected; a further confirmatory scan was Paper accepted 3 March 1995 1066 performed by the consultant vascular surgeon at this visit. Patients who fulfilled the criteria for surgery were assessed and elective aneurysm repair planned if they were deemed fit and consented to operation. If patients were unfit or declined surgery, ultrasonographic surveillance was continued. Criteria for fitness for surgery were based on those of Bernstein and Chan".Mortality data were obtained weekly from the Registrar of Births and Deaths in Chichester district before coding was undertaken, and those labelled as aortic aneurysm were checked by a clinician. The causes of death for the study population were noted, including ruptured AAA. Details of those dying outside the district but who lived locally were included. Details of operative mortality and morbidity were obtained from a prospective study started in 19814. Results Population screened and acceptance rate...

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“…Reported mortality figures following emergency repair vary between 30 and 70% [1][2][3][4][5][6], while those for elective repair are lower at 1.4-6% [1,7,8]. Furthermore, abdominal aortic aneurysms are common, with an incidence of 17-64 per 100 000 of the population in the UK [9,10], and so emergency repair of abdominal aortic aneurysm represents a significant workload for vascular surgery and critical care services.…”

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confidence: 99%

Prognostic indicators following emergency aortic aneurysm repair

Urwin¹,

Ridley²

1999

Anaesthesia

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SummaryWe performed a retrospective study of 135 patients presenting for emergency abdominal aneurysm repair to determine predictive factors for outcome. The outcome measures investigated were mortality in the operating theatre and intensive care, and at 28 and 100 days. Univariate analysis showed that the patient's age, hypotension on admission, aneurysmal rupture, pre-operative cardiopulmonary resuscitation, intra-operative blood loss and hypotension were risk factors for death either in the operating theatre or up to 100 days after surgery. Binary logistic regression identified the independent risk factors for survival. Operative survival was determined by acute factors such as pre-operative cardiopulmonary resuscitation, aneurysmal rupture and intra-operative hypotension. Longer term survival was determined by the patient's age, aneurysmal rupture, blood loss and blood pressure at admission. Using a binary logistic regression equation, from which a simplified risk score was derived, it is possible to predict the likelihood of survival of individual patients presenting for abdominal aortic aneurysm repair.

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Impact of vascular surgery on community mortality from ruptured aortic aneurysms

Cited by 199 publications

References 11 publications

The UK EndoVascular Aneurysm Repair (EVAR) randomised controlled trials: long-term follow-up and cost-effectiveness analysis

The UK EndoVascular Aneurysm Repair (EVAR) randomised controlled trials: long-term follow-up and cost-effectiveness analysis

Influence of screening on the incidence of ruptured abdominal aortic aneurysm: 5-year results of a randomized controlled study

Prognostic indicators following emergency aortic aneurysm repair

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