Red blood cell transfusion associated with increased morbidity and mortality in patients undergoing elective open abdominal aortic aneurysm repair.
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ABSTRACT: Background
Red blood cell (RBC) transfusions are associated with increased mortality and morbidity. The aim of this analysis was to examine the association between RBC transfusions and long-term survival for patients undergoing elective open infrarenal abdominal aortic aneurysm (AAA) repair with up to 15 years of follow-up.Methods
Prospective cohort study using data from The Danish Vascular Registry from 2000-2015. Primary endpoint was all-cause mortality. Secondary endpoints were in-hospital complications. Transfused patients were divided into subgroups based on received RBC transfusions (1, 2-3, 4-5 or > 5). Using Cox regression multi-adjusted analysis, non-transfused patients were compared to transfused patients (1, 2-3, 4-5, >5 transfusions) for both primary and secondary endpoints.Results
There were 3 876 patients included with a mean survival of 9.1 years. There were 801 patients who did not receive transfusions. Overall 30-day mortality was 3.1% (121 patients) and 3.6% (112) for all transfused patients. For the five subgroups 30-day mortality was: No transfusions 1.1% (9 patients), 1 RBC 1.2% (4 patients), 2-3 RBC 2.2% (26 patients), 4-5 RBC 1.9% (14 patients) and > 5 RBC 7.9% (68 patients). After receiving RBCs, the hazard ratio for death was 1.54 (95% CI 1.27-1.85) compared to non-transfused patients. There was a significant increase in mortality when receiving 2-3 RBC: HR 1.32 (95% CI 1.07-1.62), 4-5 RBC: 1.64 (1.32-2.03) and >5 RBC: 1.96 (1.27-1.85) in a multi-adjusted model.Conclusion
There is a dose-dependent association between RBC transfusions received during elective AAA repair and an increase in short- and long-term mortality. Approximately 25% of included patients had preoperative anemia. These findings should raise awareness regarding potentially unnecessary and harmful RBC transfusions.
SUBMITTER: Wedel C
PROVIDER: S-EPMC6623955 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:BACKGROUND:Evidence for benefit of endovascular aneurysm repair (EVAR) over open surgical repair for de novo infrarenal abdominal aortic aneurysms (AAAs) in younger patients remains conflicting because of heterogeneous study populations and small sample sizes. The objective of this study was to compare perioperative and short-term outcomes for EVAR and open surgery in younger patients using a large national disease and procedure-specific data set. METHODS:We identified patients 65 years of age or younger undergoing first-time elective EVAR or open AAA repair from the Vascular Quality Initiative (2003-2014). We excluded patients with pararenal or thoracoabdominal aneurysms, those medically unfit for open repair, and those undergoing EVAR for isolated iliac aneurysms. Clinical and procedural characteristics were balanced using inverse propensity of treatment weighting. A supplemental analysis extended the study to those younger than 70 years. RESULTS:We identified 2641 patients, 73% (n = 1928) EVAR and 27% (n = 713) open repair. The median age was 62 years (interquartile range, 59-64 years), and 13% were female. The median follow-up time was 401 days (interquartile range, 357-459 days). Unadjusted perioperative survival was 99.6% overall (open repair, 99.1%; EVAR, 99.8%; P < .001), with 97.4% 1-year survival overall (open repair, 97.3%; EVAR, 97.4%; P = .9). Unadjusted reintervention rates were five (open repair) and seven (EVAR) reinterventions per 100 person-years (P = .8). After propensity weighting, the absolute incidence of perioperative mortality was <1% in both groups (open repair, 0.9%, EVAR, 0.2%; P < .001), and complication rates were low. Propensity-weighted survival (hazard ratio, 0.88; 95% confidence interval, 0.56-1.38; P = .6) and reintervention rates (open repair, 6; EVAR, 8; reinterventions per 100 person-years; P = .8) did not differ between the two interventions. The analysis of those younger than 70 years showed similar results. CONCLUSIONS:In this study of younger patients undergoing repair of infrarenal AAA, 30-day morbidity and mortality for both open surgery and EVAR are low, and the absolute mortality difference is small. The prior published perioperative mortality and 1-year survival benefit of EVAR over open AAA repair is not observed in younger patients. Further studies of long-term durability are needed to guide decision-making for open repair vs EVAR in this population.
| S-EPMC5916017 | biostudies-literature
Project description:BACKGROUND:The durability of endovascular aneurysm repair (EVAR) when compared to open surgical repair (OSR) in younger patients for elective, infrarenal abdominal aortic aneurysms (AAA) remains unclear due to limited follow-up. METHODS:We identified all patients <70 years of age who underwent elective, de novo EVAR or OSR for infrarenal AAA from 2003 to 2013 in a multihospital, single institution. Baseline patient clinical and aneurysmal characteristics were adjusted for using multivariable Cox proportional hazards models and negative binomial regression. RESULTS:We identified 253 patients: 204 underwent EVAR (80.6%) and 49 OSR (19.4%). Baseline demographics and comorbidities were similar across groups. There were no deaths in the immediate perioperative period. The rate of new arrhythmia (EVAR: 1.0%, OSR: 10.2%; P = 0.004), median hospital length of stay (EVAR: 1 day, OSR: 5 days; P < 0.001), and discharge to a facility (EVAR: 2.9%, OSR: 12.2%; P = 0.016) were significantly increased for OSR. In both groups, median follow-up time was 4.5 years, in which survival did not differ between groups. The hazard of composite of freedom from death and any reinterventions (hazard ratio [HR] 4.3, P = 0.009), freedom from any reintervention (relative risk [RR] 4.08, P = 0.030), and freedom from any endovascular reintervention (RR 4.83, P = 0.038) were each higher for OSR when compared to EVAR. EVAR of the standard instruction for use (IFU) for neck length was more likely to die or undergo a reintervention (HR 4.90, P = 0.001). CONCLUSIONS:Our retrospective review of younger patients undergoing elective AAA repair demonstrated no significant differences in perioperative mortality or survival over time between EVAR and OSR. EVAR required more total reinterventions and endovascular reintervention when compared to OSR.
| S-EPMC7096248 | biostudies-literature
Project description:BackgroundThe 'weekend effect' describes the phenomenon where patient outcomes appear worse for those admitted at the weekend. It has been used recently to justify significant changes in UK health policy. Recent evidence has suggested that the effect may be due to a combination of inadequate correction for confounding factors and inaccurate coding. The effects of these factors were investigated in patients with acute abdominal aortic aneurysm (AAA).MethodsPatients undergoing non-elective AAA repair entered into the UK National Vascular Registry from January 2013 until December 2015 were included in a case-control study. The patients were divided according to whether they were treated during the week (Monday 08.00 hours to Friday 17.00 hours) or at the weekend. Data extracted included demographics, co-morbidities, preoperative medications and baseline blood test results, as well as outcomes. Coding issues were investigated by looking at patients treated for ruptured, symptomatic or asymptomatic AAA within the non-elective cohort. The primary outcome was in-hospital mortality. Secondary outcomes included length of inpatient stay, and cardiac, respiratory and renal complications.ResultsThe mortality rate appeared to be higher at the weekend (odds ratio (OR) 1·69, 95 per cent c.i. 1·47 to 1·94; P < 0·001), but this effect disappeared when confounding factors and coding issues were corrected for (corrected OR for ruptured AAA 1·09, 0·92 to 1·29; P = 0·330). Differences in outcomes were similar for prolonged length of hospital stay (uncorrected OR 1·21, 95 per cent c.i. 1·06 to 1·37, P = 0·005; corrected OR for ruptured AAA 1·06, 0·91 to 1·10, P = 0·478), and morbidity outcomes.ConclusionAfter appropriate correction for confounding factors and coding effects, there was no evidence of a significant weekend effect in the treatment of non-elective AAA in the UK.
| S-EPMC5989979 | biostudies-literature
Project description:Endovascular aneurysm repair (EVAR) has dramatically changed the management of abdominal aortic aneurysms (AAAs) as the number of open aneurysm repairs have declined over time. This report compares AAA-related demographics, operative data, complications, and mortality after treatment by open aneurysm repair or EVAR.We retrospectively reviewed 136 patients with AAAs who were treated over an 8-year time period with open aneurysm repair or EVAR.The mean age of the EVAR group was higher than that of the open repair group (p=0.001), and hospital mortality did not differ significantly between groups (p=0.360). However, overall survival was significantly lower in the EVAR group (p=0.033).Although EVAR is the primary treatment modality for elderly patients, it would be ideal to set slightly more stringent criteria within the anatomical guidelines contained in the instructions for use of the EVAR device when treating younger patients.
| S-EPMC5548202 | biostudies-other
Project description:BackgroundCurcumin, a popular herbal supplement from the plant turmeric, has prevented ischemic reperfusion and toxin-induced injury in many animal studies and a single-centre randomized human trial. We sought to test whether perioperative oral curcumin (compared with placebo) affects the inflammatory response and risk of postrepair complications after elective abdominal aortic aneurysm repair in humans.MethodsWe conducted a parallel-group, randomized, placebo-controlled trial of patients from 10 hospitals in Canada who were scheduled to undergo elective repair of an unruptured abdominal aortic aneurysm (November 2011 to November 2014). Patients in the treatment group received perioperative oral curcumin (2000-mg doses 8 times over 4 d). Patients, health care providers and local research staff were unaware of the treatment assignment. The primary outcomes were median concentrations of 4 bio markers indicating injury and inflammation (postoperative urine interleukin-18 and perioperative rise in serum creatinine, plasma N-terminal pro-B-type natriuretic peptide and plasma high-sensitivity C-reactive protein).ResultsBaseline characteristics were similar in the 2 groups (606 patients overall; median age 76 yr). More than 85% of patients in each group took more than 80% of their scheduled capsules. Neither curcumin nor placebo significantly affected any of the 4 biomarkers (p > 0.05 for all comparisons). Regarding the secondary outcomes, there was a higher risk of acute kidney injury with curcumin than with placebo (17% v. 10%, p = 0.01), but no between-group difference in the median length of hospital stay (5 v. 5 days, p > 0.9) or the risk of clinical events (9% v. 9%, p = 0.9).InterpretationCurcumin had no beneficial effects when used in elective abdominal aortic aneurysm repair. These findings emphasize the importance of testing turmeric and curcumin before espousing their health benefits, as is currently done in the popular media.Trial registrationClinicalTrials.gov, no. NCT01225094.
| S-EPMC6205831 | biostudies-literature
Project description:Importance:Knowledge regarding the long-term outcomes of elective treatment of abdominal aortic aneurysm (AAA) using endovascular aortic repair (EVAR) is increasing. However, data with greater than 10 years' follow-up remain sparse and are lacking from population-based studies. Objective:To determine the long-term outcomes of EVAR compared with open surgical repair (OSR) for elective treatment of AAA. Design, Setting, and Participants:This retrospective, population-based cohort study used linked administrative health data from Ontario, Canada, to identify all patients 40 years and older who underwent elective EVAR or OSR for AAA repair from April 1, 2003, to March 31, 2016, with follow-up terminating on March 31, 2017. A total of 17 683 patients were identified using validated procedure and billing codes and were propensity score matched. Analysis was conducted from June 26, 2018, to January 16, 2019. Exposures:Elective EVAR or OSR for AAA. Main Outcomes and Measures:The primary outcome was overall survival. Secondary outcomes were major adverse cardiovascular event-free survival, defined as being free of death, myocardial infarction, or stroke; reintervention; and secondary rupture. Results:Among 17 683 patients who received elective AAA repairs (mean [SD] age, 72.6 [7.8] years; 14 286 [80.8%] men), 6100 (34.5%) underwent EVAR and 11 583 (65.5%) underwent OSR. From these patients, 4010 well-balanced propensity score-matched pairs of patients were defined, with a mean (SD) age of 73.0 (7.6) years and 6583 (82.1%) men. In the matched cohort, the mean (SD) follow-up was 4.4 (2.7) years, and maximum follow-up was 13.8 years. The overall median survival was 8.9 years. Compared with OSR, EVAR was associated with a higher survival rate up to 1 year after repair (91.0% [95% CI, 90.1%-91.9%] vs 94.0% [95% CI, 93.3%-94.7%]) and a higher major adverse cardiovascular event-free survival rate up to 4 years after repair (69.9% [95% CI, 68.3%-71.3%] vs 72.9% [95% CI, 71.4%-74.4%]). Cumulative incidence of reintervention was higher among patients who underwent EVAR compared with those who underwent OSR at the 7-year follow-up (45.9% [95% CI, 44.1%-47.8%] vs 42.2% [95% CI, 40.4%-44.0%]). Survival analyses demonstrated no statistically significant differences in long-term survival, reintervention, and secondary rupture for patients who underwent EVAR compared with those who underwent OSR. Kaplan-Meier analysis suggested superior long-term major adverse cardiovascular event-free survival among patients who underwent EVAR compared with those who underwent OSR (32.6% [95% CI, 26.9%-38.4%] vs 14.1% [95% CI, 4.0%-30.4%]; stratified log-rank P < .001) during a maximum follow-up of 13.8 years. Conclusions and Relevance:Endovascular aortic repair was not associated with a difference in long-term survival during more than 13 years' maximum follow-up. The reasons for these findings will require studies to consider specific graft makes and models, adherence to instructions for use, and types and reasons for reintervention.
| S-EPMC6624804 | biostudies-other
Project description:OBJECTIVES:Emergency endovascular aneurysm repair (eEVAR) may improve outcomes for patients with ruptured abdominal aortic aneurysm (RAAA). The study aim was to compare the outcomes for eEVAR with conventional open surgical repair for the treatment of RAAA. SETTING:A systematic review of relevant publications was performed. Randomised controlled trials (RCTs) comparing eEVAR with open surgical repair for RAAA were included. PARTICIPANTS:3 RCTs were included, with a total of 761 patients with RAAA. INTERVENTIONS:Meta-analysis was performed with fixed-effects models with ORs and 95% CIs for dichotomous data and mean differences with 95% CIs for continuous data. PRIMARY AND SECONDARY OUTCOME MEASURES:Primary outcome was short-term mortality. Secondary outcome measures included aneurysm-specific and general complication rates, quality of life and economic analysis. RESULTS:Overall risk of bias was low. There was no difference between the 2 interventions on 30-day (or in-hospital) mortality, OR 0.91 (95% CI 0.67 to 1.22; p=0.52). 30-day complications included myocardial infarction, stroke, composite cardiac complications, renal complications, severe bowel ischaemia, spinal cord ischaemia, reoperation, amputation and respiratory failure. Reporting was incomplete, and no robust conclusion was drawn. For complication outcomes that did include at least 2 studies in the meta-analysis, there was no clear evidence to support a difference between eEVAR and open repair. Longer term outcomes and cost per patient were evaluated in only a single study, thus precluding definite conclusions. CONCLUSIONS:Outcomes between eEVAR and open repair, specifically 30-day mortality, are similar. However, further high-quality trials are required, as the paucity of data currently limits the conclusions.
| S-EPMC4762122 | biostudies-other
Project description:The benefit of prophylactic repair of abdominal aortic aneurysms (AAAs) is based on the risk of rupture exceeding the risk of death from other comorbidities. The purpose of this study was to validate a 5-year survival prediction model for patients undergoing elective repair of asymptomatic AAA <6.5 cm to assist in optimal selection of patients.All patients undergoing elective repair for asymptomatic AAA <6.5 cm (open or endovascular) from 2002 to 2011 were identified from a single institutional database (validation group). We assessed the ability of a prior published Vascular Study Group of New England (VSGNE) model (derivation group) to predict survival in our cohort. The model was assessed for discrimination (concordance index), calibration (calibration slope and calibration in the large), and goodness of fit (score test).The VSGNE derivation group consisted of 2367 patients (70% endovascular). Major factors associated with survival in the derivation group were age, coronary disease, chronic obstructive pulmonary disease, renal function, and antiplatelet and statin medication use. Our validation group consisted of 1038 patients (59% endovascular). The validation group was slightly older (74 vs 72 years; P < .01) and had a higher proportion of men (76% vs 68%; P < .01). In addition, the derivation group had higher rates of advanced cardiac disease, chronic obstructive pulmonary disease, and baseline creatinine concentration (1.2 vs 1.1 mg/dL; P < .01). Despite slight differences in preoperative patient factors, 5-year survival was similar between validation and derivation groups (75% vs 77%; P = .33). The concordance index of the validation group was identical between derivation and validation groups at 0.659 (95% confidence interval, 0.63-0.69). Our validation calibration in the large value was 1.02 (P = .62, closer to 1 indicating better calibration), calibration slope of 0.84 (95% confidence interval, 0.71-0.97), and score test of P = .57 (>.05 indicating goodness of fit).Across different populations of patients, assessment of age and level of cardiac, pulmonary, and renal disease can accurately predict 5-year survival in patients with AAA <6.5 cm undergoing repair. This risk prediction model is a valid method to assess mortality risk in determining potential overall survival benefit from elective AAA repair.
| S-EPMC6114131 | biostudies-literature
Project description:BACKGROUND:There is substantial international variation in mortality after abdominal aortic aneurysm (AAA) repair; many non-operative factors influence risk-adjusted outcomes. This study compared 90-day and 5-year mortality for patients undergoing elective AAA repair in England and Sweden. METHODS:Patients were identified from English Hospital Episode Statistics and the Swedish Vascular Registry between 2003 and 2012. Ninety-day mortality and 5-year survival were compared after adjustment for age and sex. Separate within-country analyses were performed to examine the impact of co-morbidity, hospital teaching status and hospital annual caseload. RESULTS:The study included 36 249 patients who had AAA treatment in England, with a median age of 74 (i.q.r. 69-79) years, of whom 87·2 per cent were men. There were 7806 patients treated for AAA in Sweden, with a median of age 73 (68-78) years, of whom 82·9 per cent were men. Ninety-day mortality rates were poorer in England than in Sweden (5·0 versus 3·9 per cent respectively; P < 0·001), but were not significantly different after 2007. Five-year survival was poorer in England (70·5 versus 72·8 per cent; P < 0·001). Use of EVAR was initially lower in England, but surpassed that in Sweden after 2010. In both countries, poor outcome was associated with increased age. In England, institutions with higher operative annual volume had lower mortality rates. CONCLUSION:Mortality for elective AAA repair was initially poorer in England than Sweden, but improved over time alongside greater uptake of EVAR, and now there is no difference. Centres performing a greater proportion of EVAR procedures achieved better results in England.
| S-EPMC5900926 | biostudies-literature
Project description:BackgroundThe sharp decrease in open surgical repair (OSR) for abdominal aortic aneurysm (AAA) has raised concerns about contemporary postoperative outcomes. The study was designed to analyse the impact of complications on clinical outcomes within 30 days following OSR.MethodsPatients who underwent OSR for intact AAA registered prospectively between 2016 and 2019 in the Dutch Surgical Aneurysm Audit were included. Complications and outcomes (death, secondary interventions, prolonged hospitalization) were evaluated. The adjusted relative risk (aRr) and 95 per cent confidence intervals were computed using Poisson regression. Subsequently, the population-attributable fraction (PAF) was calculated. The PAF reflects the expected percentage reduction of an outcome if a complication were to be completely prevented.ResultsA total of 1657 patients were analysed. Bowel ischaemia and renal complications had the largest impact on death (aRr 12·44 (95 per cent c.i. 7·95 to 19·84) at PAF 20 (95 per cent c.i. 8·4 to 31·5) per cent and aRr 5·07 (95 per cent c.i. 3·18 to 8.07) at PAF 14 (95 per cent c.i. 0·7 to 27·0) per cent, respectively). Arterial occlusion had the greatest impact on secondary interventions (aRr 11·28 (95 per cent c.i. 8·90 to 14·30) at PAF 21 (95 per cent c.i. 14·7 to 28·1) per cent), and pneumonia (aRr 2·52 (95 per cent c.i. 2·04 to 3·10) at PAF 13 (95 per cent c.i. 8·3 to 17·8) per cent) on prolonged hospitalization. Small effects were observed on outcomes for other complications.ConclusionThe greatest clinical impact following OSR can be made by focusing on measures to reduce the occurrence of bowel ischaemia, arterial occlusion and pneumonia.
| S-EPMC8438252 | biostudies-literature