Mortality variability after endovascular versus open abdominal aortic aneurysm repair in a large tertiary vascular center using a Medicare-derived risk prediction model

Caitlin W Hicks; James H Black 3rd; Isibor Arhuidese; Luda Asanova; Umair Qazi; Bruce A Perler; Julie A Freischlag; Mahmoud B Malas

doi:10.1016/j.jvs.2014.04.078

Mortality variability after endovascular versus open abdominal aortic aneurysm repair in a large tertiary vascular center using a Medicare-derived risk prediction model

J Vasc Surg. 2015 Feb;61(2):291-7. doi: 10.1016/j.jvs.2014.04.078. Epub 2014 Aug 22.

Authors

Caitlin W Hicks¹, James H Black 3rd¹, Isibor Arhuidese¹, Luda Asanova¹, Umair Qazi¹, Bruce A Perler¹, Julie A Freischlag¹, Mahmoud B Malas²

Affiliations

¹ Division of Vascular and Endovascular Therapy, Johns Hopkins Bayview Medical Center and Johns Hopkins Hospital, Baltimore, Md.
² Division of Vascular and Endovascular Therapy, Johns Hopkins Bayview Medical Center and Johns Hopkins Hospital, Baltimore, Md. Electronic address: [email protected].

PMID: 25154686
DOI: 10.1016/j.jvs.2014.04.078

Abstract

Objective: Previous reports have documented better outcomes after open abdominal aortic aneurysm (AAA) repair in tertiary centers compared with lower-volume hospitals, but outcome variability for endovascular AAA repair (EVAR) vs open AAA repairs in a large tertiary center using a Medicare-derived mortality risk prediction model has not been previously reported. In the current study, we compared the observed vs predicted mortality after EVAR and open AAA repair in a single large tertiary vascular center.

Methods: We retrospectively analyzed all patients who underwent repair of a nonruptured infrarenal AAA in our center from 2003 to 2012. Univariable and multivariable logistic regression were used to evaluate 30-day mortality. Patients were stratified into low-risk, medium-risk, and high-risk groups, and mortality was predicted for each patient based on demographics and comorbidities according to the Medicare risk prediction model.

Results: We analyzed 297 patients (EVAR, 72%; open AAA repair, 28%; symptomatic, 25%). Most of our patients were of high and moderate risk (48% and 28%, respectively). The observed 30-day mortality was 1.9% after EVAR vs 2.4% after open repair (odds ratio [OR], 0.77; 95% confidence interval [CI], 0.14-4.29; P = .67). There was no difference in mortality with EVAR vs open repair after adjusting for predefined patient characteristics (OR, 0.92; 95% CI, 0.16-7.43; P = .93); only preoperative renal disease was predictive of 30-day mortality after AAA repair in our cohort (OR, 8.39; 95% CI, 1.41-67.0). The observed mortality within our study was significantly lower than the Medicare-derived expected mortality for each treatment group within patients stratified as high risk or medium risk (P ≤ .0002 for all).

Conclusions: Despite treating patients with high preoperative risk status, we report a 10-fold decrease in operative mortality for EVAR and open AAA repair in a tertiary vascular center compared with national Medicare-derived predictions. High-risk patients should be considered for aneurysm management in dedicated aortic centers, regardless of approach.

Publication types

Comparative Study

MeSH terms

Aged
Aortic Aneurysm, Abdominal / diagnosis
Aortic Aneurysm, Abdominal / mortality
Aortic Aneurysm, Abdominal / surgery*
Chi-Square Distribution
Decision Support Techniques*
Endovascular Procedures / adverse effects
Endovascular Procedures / mortality*
Female
Humans
Logistic Models
Male
Medicare*
Multivariate Analysis
Odds Ratio
Patient Selection
Retrospective Studies
Risk Assessment
Risk Factors
Tertiary Care Centers*
Time Factors
Treatment Outcome
United States / epidemiology
Vascular Surgical Procedures / adverse effects
Vascular Surgical Procedures / mortality*