Invited commentary

Abstract

This carefully performed analysis of the National Inpatient Sample database highlights both the strengths and weaknesses of “big data” in our quest for improving patient outcomes from the complications of vascular disease. Despite significantly greater comorbidities, the thoracic endovascular aortic repair (TEVAR) group had better hospital outcomes than the group undergoing open repair, in all venues. The substantial increase in TEVAR over nonoperative management reflects the physician's and patient's perception that “minimally invasive” techniques deserve application in populations that were previously believed unfit for open repair, and the decreased in-hospital mortality would appear to support this position. What is reassuring is that improved early outcomes support that TEVAR is a welcome addition to the management of a complex and often fatal problem. What the study does not address—and by the nature of the database is incapable of doing—is the long-term outcome for the patients offered treatment, particularly for the very elderly, who have experienced the greatest increase in intervention. With acute renal failure and respiratory failure occurring in 22% and 33%, respectively, and discharge to home of only 27%, the long-term impact on quality of life may not reflect the same optimism associated with a decreasing hospital mortality. Whereas the introduction of less invasive therapies has clearly broadened the eligibility for patients at high risk or unfit for traditional open repair, we must be cautious to ensure that short-term markers of success, particularly in-hospital mortality, are balanced against patient-centered expectations. Hospital readmissions, a useful surrogate for a successful result, cannot be linked with the National Inpatient Sample database. It is possible that using linked hospital data will improve our understanding of the long-term outcomes of our interventions. Using the Medicare/Centers for Medicare and Medicaid Services database, Schaffer et al1Schaffer J.M. Lingala B. Miller D.C. Woo Y.J. Mitchell R.S. Dake M.D. Midterm survival after thoracic endovascular aortic repair in more than 10,000 Medicare patients.J Thorac Cardiovasc Surg. 2015; 149: 808-820Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar demonstrated substantially worse early and midterm (5-year) mortality for TEVAR patients presenting with rupture. Crude measures of late mortality, however, do little to help us understand which patients recover to independence and which have a significant reduction in the quality of their lives. Predictors of outcome with elective abdominal aneurysm repair have begun to explore functional status2Endicott K.M. Emerson D. Amdur R. Macsata R. Functional status as a predictor of outcomes in open and endovascular abdominal aortic aneurysm repair.J Vasc Surg. 2017; 65: 40-45Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar and frailty3Arya S. Kim S.I. Duwayri Y. Brewster L.P. Veeraswamy R. Salam A. et al.Frailty increases the risk of 30-day mortality, morbidity, and failure to rescue after elective abdominal aortic aneurysm repair independent of age and comorbidities.J Vasc Surg. 2015; 61: 324-331Abstract Full Text Full Text PDF PubMed Scopus (158) Google Scholar as independent predictors of poor outcomes, with impact beyond the traditional risks of heart failure, cerebrovascular diseases, and renal failure. The accuracy of several ruptured aneurysm scoring systems to predict futility has been challenged,4Thompson P.C. Dalman R.L. Harris E.J. Chandra V. Lee J.T. Mell M.W. Predictive models for mortality after ruptured aortic aneurysm repair do not predict futility and are not useful for clinical decision making.J Vasc Surg. 2016; 64: 1617-1622Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar and this relates only to mortality. It remains the responsibility of the surgeon to help patients understand how their individual situation relates to predictive algorithms.5Sniderman A.D. D'Agostino Sr., R.B. Pencina M.J. The role of physicians in the era of predictive analytics.JAMA. 2015; 314: 25-26Crossref PubMed Scopus (50) Google Scholar We owe it to our patients to place our ability to perform a procedure in the context of our patient's goals, it is to be hoped with sound predictive data to support these decisions. The impact of endovascular repair on management and outcome of ruptured thoracic aortic aneurysmsJournal of Vascular SurgeryVol. 66Issue 2PreviewThoracic endovascular aortic repair (TEVAR) has become an alternative to open repair for the treatment of ruptured thoracic aortic aneurysms (rTAAs). The aim of this study was to assess national trends in the use of TEVAR for the treatment of rTAA and to determine its impact on perioperative outcomes. Full-Text PDF Open Archive