Regional variation in endovascular treatment rate and in-hospital mortality of abdominal aortic aneurysms in Germany

Abstract

Summary: Background: Abdominal aortic aneurysms (AAA) can be treated by either open surgery (OAR) or endovascular aortic repair (EVAR). The aim of this study was to analyze regional variations in application of (EVAR) and in-hospital mortality after intact AAA (iAAA) repair. Methods: Using data provided by the German Federal Statistical Office, a nationwide analysis for 2012 to 2014 was conducted. Patients with a diagnosis of iAAA (I71.4) and corresponding procedure codes for OAR (5-384.5/7) or EVAR (5-38a.1) were included. Odds ratios (ORs) for use of EVAR (proportion of EVAR among total EVAR + OAR cases) and mortality were calculated for all regions in Germany. ORs for EVAR use were adjusted for age, sex, and risk (Elixhauser score). ORs for mortality were additionally adjusted for type of procedure (OAR/EVAR). Results: Finally, 31,757 procedures for iAAA were included. Median age of all patients was 73 years (interquartile range 67–78 years) and 87.1 % were male. The mean proportion of EVAR procedures was 72.6 %; however, the application of EVAR for repair of iAAA varied widely depending on region. The lowest unadjusted regional rate of EVAR use was 48.8 %, while the highest was 92.5 %. After adjustment, the lowest regional OR for EVAR use (compared to the nationwide mean) was 0.23 (95 % confidence interval [0.15–0.36]), the highest 5.93 [1.79–19.65]. Overall in-hospital mortality was 2.9 % (OAR 6.2 %; EVAR 1.7 %). The adjusted regional OR for mortality ranged from 0.31 [0.07–1.42] to 4.98 [2.08–11.93]. Conclusions: This study reveals variations in use of EVAR and in-hospital mortality for iAAA treatment in Germany. This may imply that selection of treatment might not only be influenced by patient characteristics, but also by regional location. These results need to be taken into account when discussing centralization of AAA treatment in Germany.

Aneurysms and dissections - What is new in the literature of 2019/2020 - a European Society of Vascular Medicine annual review

“…The mean proportion of EVAR procedures was 72.6%; however, the application of EVAR for repair of intact AAA varied widely depending on region: the lowest unadjusted regional rate of EVAR use was 48.8%, while the highest was 92.5%. Overall inhospital mortality was 2.9% (OAR 6.2%; EVAR 1.7%) [218]. The influence of precedural volumes was also confirmed by Scali et al (Vizient database, 3,449 pts) and the analysis of the Australasian Vascular Audit database of 14,262 aneurysm repair procedures between 2010 and 2016 [219].…”

Can endovascular repair be the first-line treatment option in abdominal aortic aneurysms during COVID-19 pandemic?

“…[8] This treatment modality has been used for the treatment of AAAs in 67.2% patients in the United Kingdom, 72.6% patients in Germany (72.6%), 75.4% patients in the United States. [9] To utilize healthcare services effectively, treatment of AAAs in elderly patients requiring open surgical repair should be first postponed during the pandemic, since the need for ICU stay and a higher amount of healthcare resources in this patient population. [10][11][12] The rate of ICU need is as low as 1% in patients undergoing elective EVAR and requires minimum utilization of healthcare resources such as personnel, mask, and gown.…”

Evolution of Practices in Treatment of Abdominal Aortic Aneurysm in France between 2006 and 2015

“…Moreover, if hospitals intend to remain at the same level of quality currently achieved in open surgery in terms of morbidity and mortality, they must maintain a sufficient number of procedures. In aortic surgery, as in other types of surgery, it has been proven that the quality of care is directly linked to the volume of activity 30,31 The LOS observed seemed lengthy, regardless of the type of surgery and institution. For open repair, LOS remained the same in the period despite the increase in complex surgeries.…”