Peter J. Holt

Meta‐analysis and systematic review of the relationship between volume and outcome in abdominal aortic aneurysm surgery

This study investigated the volume–outcome relationship for abdominal aortic aneurysm (AAA) surgery and quantified critical volume thresholds.

Lower extremity amputations — a review of global variability in incidence

Diabet. Med. 28, 1144–1153 (2011)

Mortality from ruptured abdominal aortic aneurysms: clinical lessons from a comparison of outcomes in England and the USA

BACKGROUND The outcome of patients with ruptured abdominal aortic aneurysm (rAAA) varies by country. Study of practice differences might allow the formulation of pathways to improve care. METHODS We compared data from the Hospital Episode Statistics for England and the Nationwide Inpatient Sample for the USA for patients admitted to hospital with rAAA from 2005 to 2010. Primary outcomes were in-hospital mortality, mortality after intervention, and decision to follow non-corrective treatment. In-hospital mortality and the rate of non-corrective treatment were analysed by binary logistic regression for each health-care system, after adjustment for age, sex, year, and Charlson comorbidity index. FINDINGS The study included 11,799 patients with rAAA in England and 23,838 patients with rAAA in the USA. In-hospital mortality was lower in the USA than in England (53·05% [95% CI 51·26-54·85] vs 65·90%; p<0·0001). Intervention (open or endovascular repair) was offered to a greater proportion of cases in the USA than in England (19,174 [80·43%] vs 6897 [58·45%]; p<0·0001) and endovascular repair was more common in the USA than in England (4003 [20·88%] vs 589 [8·54%]; p<0·0001). Postintervention mortality was similar in both countries (41·77% for England and 41·65% for USA). These observations persisted in age-matched and sex-matched comparisons. In both countries, reduced mortality was associated with increased use of endovascular repair, increased hospital caseload (volume) for rAAA, high hospital bed capacity, hospitals with teaching status, and admission on a weekday. INTERPRETATION In-hospital survival from rAAA, intervention rates, and uptake of endovascular repair are lower in England than in the USA. In England and the USA, the lowest mortality for rAAA was seen in teaching hospitals with larger bed capacities and doing a greater proportion of cases with endovascular repair. These common factors suggest strategies for improving outcomes for patients with rAAA. FUNDING None.

Modern Treatment of Juxtarenal Abdominal Aortic Aneurysms with Fenestrated Endografting and Open Repair ― A Systematic Review

INTRODUCTION Advances in endovascular technology have led to the introduction of fenestrated stents to treat juxtarenal aneurysms (JRAs), previously deemed unsuitable for standard endovascular repair (EVR). This article reviews the outcomes of fenestrated technology and makes a comparison with open repair. METHODS A systematic review of the literature was performed. RESULTS No randomised studies were identified. 8 cohort studies reporting 368 f-EVR cases and 12 cohorts reporting 1164 open repairs of JRAs were identified. Analysis of outcome measures found the f-EVR and open cohorts to be homogeneous. Combining studies identified an increased 30-day mortality after open repair when compared to f-EVR (Relative risk (RR) 1.03, 95% Confidence interval (CI) 1.01-1.04, p=.02), 2% increased absolute mortality. No difference was identified in postoperative permanent dialysis dependence (RR 1.00, CI 0.99-1.01, p=1). Transient renal failure was more common following open repair (RR 1.06, CI 1.01-1.12, p=.03). Early re-interventions were less common following open repair (RR 0.87, CI 0.83-0.91, p=.0001). CONCLUSIONS Selective f-EVR appears to have reduced peri-operative mortality compared with traditional open surgery, yet selectivity within the study groups and lack of a rigorous classification prohibit more robust comparison. Promising short-term results confirm a role for f-EVR in management of complex abdominal aneurysms.

Epidemiological study of the relationship between volume and outcome after abdominal aortic aneurysm surgery in the UK from 2000 to 2005

The aim was to assess the relationship between hospital volume and outcome after abdominal aortic aneurysm (AAA) surgery in the UK.

A Systematic Review of Mid-term Outcomes of Thoracic Endovascular Repair (TEVAR) of Chronic Type B Aortic Dissection

OBJECTIVE AND DESIGN The role of Thoracic Endovascular Repair (TEVAR) in chronic type B aortic dissection remains controversial and its mid-term success as an alternative to open repair or best medical therapy remains unknown. The aim of the present study was to provide a systematic review of mid-term outcomes of TEVAR for chronic type B aortic dissection. MATERIALS AND METHODS Medline, trial registries, conference proceedings and article reference lists from 1950 to January 2011 were searched to identify case series reporting mid-term outcomes of TEVAR in chronic type B dissection. Data were extracted for review. RESULTS 17 studies of 567 patients were reviewed. The technical success rate was 89.9% (range 77.6-100). Mid-term mortality was 9.2% (46/499) and survival ranged from 59.1 to 100% in studies with a median follow-up of 24 months. 8.1% of patients (25/309) developed endoleak, predominantly type I. Re-intervention rates ranged from 0 to 60% in studies with a median follow-up of 31 months. 7.8% of patients (26/332) developed aneurysms of the distal aorta or continued false lumen perfusion with aneurysmal dilatation. Rare complications included delayed retrograde type A dissection (0.67%), aorto-oesophageal fistula (0.22%) and neurological complications (paraplegia 2/447, 0.45%; stroke 7/475, 1.5%). CONCLUSION The absolute benefit of TEVAR over alternative treatments for chronic B-AD remains uncertain. The lack of natural history data for medically treated cases, significant heterogeneity in case selection and absence of consensus reporting standards for intervention are significant obstructions to interpreting the mid-term data. High-quality data from registries and clinical trials are required to address these challenges.

Endovascular Aneurysm Repair with Preservation of the Internal Iliac Artery Using the Iliac Branch Graft Device

OBJECTIVES Aortoiliac aneurysms comprise up to 43% of the specialist endovascular caseload. In such cases endovascular aneurysm repair (EVAR) requires distal extension of the aortoiliac endograft beyond the ostium of the internal iliac artery (IIA) and into the external iliac artery, conventionally necessitating the embolisation of one or both IIA. This has been associated with a wide range of complications, and the use of an Iliac Branch-graft Device (IBD) offers an appealing endovascular solution. DESIGN Medline, trial registries, conference proceedings and article reference lists were searched to identify case series reporting IBD use. Data were extracted for review. RESULTS Nine series have reported the use of IBD in a total of 196 patients. Technical success was 85-100%. Median operating times were 101-290min and median contrast dose was 58-208g, with no aneurysm-related mortality. Claudication developed in 12/24 patients after IBD occlusion. One type I endoleak and two type III endoleaks occurred and were managed endovascularly. Re-occlusion occurred in 24/196 patients. CONCLUSION IBD was performed with high technical success rates and encouraging mid-term patency. Formalised risk stratification and morphological data are required to identify the group of patients who will benefit most. Cost-effectiveness appraisals are needed for this technique.

Meta-analysis of randomized controlled trials comparing laparoscopic with open mesh repair of recurrent inguinal hernia.

Although there is plentiful evidence regarding the use of laparoscopic surgery for primary inguinal hernia, there is a paucity of literature concerning its role after recurrence. There has been no quantitative review of the evidence, despite suggestions that pooled analysis of existing data is required.

Effect of Endovascular Aneurysm Repair on the Volume–Outcome Relationship in Aneurysm Repair

Background—We aim to quantify the relationship between the annual caseload (volume) and outcome from elective endovascular (EVR) or open repair of abdominal aortic aneurysms (AAAs) in England between 2005 and 2007. Methods and Results—Individual patient data were obtained from the Hospital Episode Statistics. Statistical methods included multiple logistic regression models, mortality control charts, and safety plots to determine the nature of any relationship between volume and outcome. The case-mix between hospitals of different sizes was examined using observed and expected values for in-hospital mortality. Outcome measures included in-hospital mortality and hospital length of stay. Between 2005 and 2007, a total of 57587 patients were admitted to hospitals in England with a diagnosis of AAA, and 11574 underwent AAA repair. There were 7313 elective AAA repairs, of which 5668 (78%) were open and 1645 (22%) were EVR. In-hospital mortality rates were 5.63% for all elective AAA repairs with rates of 6.18% for open repair and 3.77% for EVR (odds ratio, 0.676; 95% CI, 0.501 to 0.913; P=0.011). High-volume aneurysm services were associated with significantly lower mortality rates overall (0.991; 0.988 to 0.994; P<0.0001), for open repairs (0.994; 0.991 to 0.998; P=0.0008), and EVR (0.989; 0.982 to 0.995; P=0.0007). Large endovascular units had low mortality rates for open repairs. Conclusion—A strong relationship existed between the volume of surgery performed and outcome from both open and endovascular aneurysm repairs. These data support the concept that abdominal aortic surgery should be performed in specialized units that meet a minimum volume threshold.

Epidemiological study of lower limb amputation in England between 2003 and 2008

The purpose of this study was to investigate the prevalence of lower extremity amputation in England, to establish the associated mortality, and to determine the relationship with diabetes mellitus and previous revascularization.