Trends in management and outcomes of vascular emergencies in the nationwide inpatient sample.

Abstract

Background: To evaluate trends in frequency, mortality and treatment for non-traumatic vascular emergencies (VE) in the US. Methods: VE in the Nationwide Inpatient Sample (2005-2014) were identified. ICD-9 CM diagnosis and procedures codes captured six common VE. Results: 228,210,504 emergency admissions with 317,396 procedures for VE were estimated. Mean age was 67.8years and were primarily men (56.1%; p < 0.0001). The commonest VE was Acute Limb Ischemia (ALI) (82.4%) followed by ruptured AAA (10.8%) and Acute Mesenteric Ischemia (4.71%). VE increased from 132.8 per 100,000 admissions in 2005 to 153.6 in 2014 (p < 0.001), with mortality decrease for all VE (13.8% vs. 9.1%; p<0.0001). Length of stay decreased (median 8 vs. 7 days; p < 0.0001) but cost of care increased (median $25,443 vs. $29,353; p < 0.0001). Endovascular treatment increased overall for VE from 23.7% in 2005 to 37.2% in 2014 (p < 0.0001). Hospital mortality for VE decreased overall, except ruptured thoracoabdominal aortic aneurysm with mortality decrease with endovascular treatment (34.3 vs. 11.1; p= 0.04) and mortality increase with open treatment (44.7 vs. 47.6; p = 0.06). ALI overall mortality decreased from 8.1% to 5.7% (p < 0.0001) due to reduced open surgical mortality from 9.6% to 7.4% (p < 0.0001); endovascular mortality did not improve over time (4.0% vs. 3.4%; p = 0.45). Hospital mortality also increased for endovascular treatment of ruptured thoracic aortic aneurysm (rTAA) from 14.9% to 27.4% (p = 0.0003) during this period. Conclusions: VE frequency increased with a decrease in overall mortality over time. Overall hospital stay has decreased but with an increase in the cost of care. Open surgical mortality for VE has also decreased overall, suggesting perioperative care improvements, with the exception of ruptured thoracoabdominal aortic aneurysm. Endovascular utilization for VE has significantly increased; associated with lower mortality for most VE, although an increase in hospital mortality after endovascular repair of rTAA was seen. This may be due to an increased implementation of endovascular repair for patients not previously eligible for surgery due to high risk. We recommend careful selection of patients for rTAA treatment as mortality has increased despite endovascular therapy and at an increased cost of care.