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Abstract

We appreciate the opportunity to respond to comments made by Filis and Galyfos. Regarding their first point, that “unsatisfactory results” should be further explained, we are, unfortunately, limited by the constraints of using a clinical registry without being able to further define each preset collected data measure from contributing hospitals nationally. Only one indication for each procedure is captured within the National Surgical Quality Improvement Program (NSQIP), and clinical reviewers take this directly from the operative note of the treating physician. Therefore, determining what consisted of an unsatisfactory result of prior repair, whether by endovascular aneurysm repair (EVAR) or open repair, is left to the discretion of the treating physician. Inclusion of this group in patients undergoing repair of asymptomatic aneurysms would only increase the 30-day mortality and morbidity, making the difference between asymptomatic and symptomatic aneurysms that much more striking. We also did not want to include acute conversions from EVAR to open repair because there were too few cases of this for a meaningful analysis, we did not have enough data to describe what led to the conversion, and it was outside of the scope of our manuscript. For the second point, we agree that symptomatic aneurysms could potentially be misdiagnosed; however, all patients identified as having symptomatic aneurysms in the NSQIP were diagnosed by the treating physician, and therefore, we believe the diagnosis was as accurate as possible. The NSQIP defines symptomatic as an aneurysm causing abdominal or back pain or causing local compressive symptoms and that is not ruptured. Furthermore, we believe the strength and utility of clinical registries is demonstrated in our manuscript, which allowed for the analysis of a much greater number of symptomatic aneurysms than was previously possible.1De Martino R.R. Nolan B.W. Goodney P.P. Chang C.K. Schanzer A. Cambria R. et al.Outcomes of symptomatic abdominal aortic aneurysm repair.J Vasc Surg. 2010; 52: 5-12.e1Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar In the analysis by Lo et al,2Lo R.C. Lu B. Fokkema M.T. Conrad M. Patel V.I. Fillinger M. et al.Vascular Study Group of New EnglandRelative importance of aneurysm diameter and body size for predicting abdominal aortic aneurysm rupture in men and women.J Vasc Surg. 2014; 59: 1209-1216Abstract Full Text Full Text PDF PubMed Scopus (136) Google Scholar only patients undergoing surgery ≤24 hours of symptom onset were included in the intact aneurysm group, and there was a much lower use of EVAR for repair of intact and ruptured aneurysms (53% EVAR for intact aneurysms in Lo et al2Lo R.C. Lu B. Fokkema M.T. Conrad M. Patel V.I. Fillinger M. et al.Vascular Study Group of New EnglandRelative importance of aneurysm diameter and body size for predicting abdominal aortic aneurysm rupture in men and women.J Vasc Surg. 2014; 59: 1209-1216Abstract Full Text Full Text PDF PubMed Scopus (136) Google Scholar vs 80% for intact aneurysms in our analysis), making a direct comparison difficult. However, we agree that aneurysm diameter is not the perfect measure of risk for rupture and that additional measures, such as aortic size index and sac contour and growth rate, are also important predictors of rupture. Finally, we agree that timing is important and that certain symptomatic aneurysms are more likely to rupture than others, especially when taking into account the inclusion of aneurysms causing pain and also those causing locally compressive symptoms, as mentioned in our manuscript. Unfortunately we are unable to identify within the NSQIP the exact time of admission and operation because these are recorded by hospital day and not hours. We do agree that it is important for future research to identify potential radiographic and laboratory markers that could help stratify risk of rupture among patients with symptomatic aneurysms. Currently, NSQIP data are unable to answer these questions. Regarding “Outcomes for symptomatic abdominal aortic aneurysms in the American College of Surgeons National Surgical Quality Improvement Program”Journal of Vascular SurgeryVol. 65Issue 5PreviewWe have read with great interest the recently published study by Soden et al,1 where the authors have tried to evaluate and compare major postoperative outcomes among patients treated for asymptomatic, symptomatic, and ruptured abdominal aortic aneurysms (AAAs). However, some points need to be made. Full-Text PDF Open Archive