Invited commentary

Abstract

Predictive assessment of mortality and morbidity remains an important component of preoperative evaluation of any surgical procedure. Most preoperative risk assessment models have been developed for open surgical procedures with variable predictability.1Forbes T.L. Steiner S.H. Lawlor D.K. DeRose G. Harris K.A. Risk adjusted analysis of outcomes following elective open abdominal aortic aneurysm repair.Ann Vasc Surg. 2003; 19: 142-148Abstract Full Text Full Text PDF Scopus (22) Google Scholar, 2Huber T.S. Wang J.G. Derrow A.E. Dame D.A. Ozaki C.K. Zelenock G.B. et al.Experience in the United States with intact abdominal aortic aneurysm repair.J Vasc Surg. 2004; 33: 304-311Abstract Full Text Full Text PDF Scopus (141) Google Scholar The introduction and widespread use of less invasive surgical procedures, either by laparoscopic or endovascular techniques has heightened the need for developing new risk models that could predict postoperative mortality and morbidity. Treatment of abdominal aortic aneurysm has undergone dramatic changes in the last two decades. Despite the many advances in anesthetic management, preoperative risk factor modifications, and postoperative care, the 30-day mortality has remained between 3% and 5% with higher mortality and morbidity in high-risk patients.3Dardik A. Lin J.W. Gordon J.A. Williams M. Perler B.A. Results of elective abdominal aneurysm repair in 1990s: a population-based analysis of 2335 cases.J Vasc Surg. 1999; 30: 985-995Abstract Full Text Full Text PDF PubMed Scopus (206) Google Scholar Despite the significant threefold reduction in mortality in single centers, statewide databases and randomized trials, compared with conventional open repair, no analysis of criteria has been performed that can objectively identify those risk factors that increase 30-day mortality in endovascular aneurysm repair (EVAR). The EVAR 2 trial used a series of medical risk factors and “pragmatic” approaches to deem a patient unsuitable for AAA repair.4EVAR Trial ParticipantsEndovascular aneurysm repair and outcome in patients unfit for open repair of abdominal aortic aneurysm (EVAR Trial 2): Randomized controlled trial.Lancet. 2005; 365: 2187-2192Abstract Full Text Full Text PDF PubMed Scopus (613) Google Scholar Our group reported much lower 30-day mortality (2.9% vs 9%) for high-risk patients compared with EVAR 2 trial based on medical comorbidities.5Sicard G.A. Zwolak R.M. Sidawy A.N. White R.A. Siami F.S. Society for Vascular Surgery Outcomes CommitteeEndovascular abdominal aortic aneurysm repair: long-term outcome measure in patient at high-risk for open surgery.J Vasc Surg. 2006; 44: 229-236Abstract Full Text Full Text PDF PubMed Scopus (149) Google Scholar Both reports were based on risk factors commonly used to predict mortality in open repair not specific to EVAR. In this issue, Drs Egorova, Giacovelli, and collaborators describe an extensive analysis of the Inpatient Medicare database of patients with elective abdominal aortic aneurysm (AAA) repair from 2000 to 2006 and develop a risk model of preoperative 30-day mortality in over 66,000 patients treated by EVAR. Although some of the preoperative comorbidities that predict higher 30-day mortality are similar to those described for open repair, some factors are different and other similar factors have a different predictor effect on 30-day outcomes. This preoperative score, as a predictor of 30-day mortality, provides for the first time, an objective indicator of the mortality risk specific for EVAR in high-risk patients. Another important observation of this report is the identification of a very small number of EVAR candidates that are truly very high-risk even for this less invasive procedure. This preoperative predictive score will be of great utility to interventionalists who frequently perform EVAR. Defining high-risk patients for endovascular aneurysm repairJournal of Vascular SurgeryVol. 50Issue 6PreviewEndovascular aneurysm repair (EVAR) is commonly used as a minimally invasive technique for repairing infrarenal aortic aneurysms. There have been recent concerns that a subset of high-risk patients experience unfavorable outcomes with this intervention. To determine whether such a high-risk cohort exists and to identify the characteristics of these patients, we analyzed the outcomes of Medicare patients treated with EVAR from 2000-2006. Full-Text PDF Open Archive