Prue Cowled

Self-reported fitness of American Society of Anesthesiologists class 3 patients undergoing endovascular aneurysm repair predicts patient survival

BACKGROUND Most patients undergoing elective endovascular aneurysm repair (EVAR) are classified American Society of Anesthesiologists (ASA) 3. However, the severity of systemic disease among these patients can vary, resulting in markedly different levels of fitness. In this study, we explored the hypothesis that ASA 3 patients with good self-reported exercise tolerance have better survival after EVAR. METHODS Data for EVAR patients classified ASA 3 were extracted retrospectively from a prospectively collected registry database. Patients were split into two groups according to fitness level, based on their self-reported ability to climb stairs or to walk briskly for 1 km. Patient survival for each group was assessed by Cox proportional hazards models. RESULTS During follow-up of 392 patients for a mean of 1.9 years, there were 64 deaths (16.3%), 13.4% in the more physically able group and 21.6% in the less able group. Self-reported inability to walk or to climb stairs was associated with increased risk of all-cause mortality (hazard ratio, 3.55; P < .0001). Following risk adjustment for a number of possible confounding variables, fitness remained significant (hazard ratio, 3.03; P = .0011). CONCLUSIONS This study has shown that among ASA 3 patients, self-reported exercise capacity is an excellent means of predicting survival. Physicians should consider the physical fitness of their ASA 3 patients when discussing treatment options.

International trends in patient selection for elective endovascular aneurysm repair: sicker patients with safer anatomy leading to improved 1-year survival.

BACKGROUND To review the trends in patient selection and early death rate for patients undergoing elective endovascular repair of infrarenal abdominal aortic aneurysms (EVAR) in 3 countries. For this study, audit data from 4,163 patients who had undergone elective infrarenal EVAR were amalgamated. The data originated from Australia, Canada (Ontario), and England (London, Cambridge, and Leicester). METHODS Statistical analyses were undertaken to determine whether patient characteristics and early death rate varied between and within study groups and over time. The study design was retrospective analysis of data collected prospectively between 1999 and 2012. RESULTS One-year survival improved over time (P = 0.0013). Canadian patients were sicker than those in Australia or England (P < 0.001). American Society of Anesthesiologists classification (ASA) increased over time across all countries although more significantly in Canada. Age at operation remained constant, although older patients were treated more recently in London (P < 0.001). English centers treated larger aneurysms compared with Australia and Canada (P < 0.001). Australian centers treated a much larger proportion of aneurysms that were <55 mm than other countries. Preoperative creatinine levels decreased over time for all countries and centers (P < 0.001). Infrarenal neck angles have significantly decreased over time (P < 0.001). Recent data from London (UK) showed that operations were performed on longer (P < 0.001) and wider (P < 0.001) infrarenal necks than elsewhere. CONCLUSIONS In this international comparison, several trends were noted including improved 1-year survival despite declining patient health (as measured by increasing ASA status). This may reflect greater knowledge regarding EVAR that centers from different countries have gained over the last decade and improved medical management of patients with aneurysmal disease.

Fitness plus American Society of Anesthesiologists grade improve outcome prediction after endovascular aneurysm repair.

Although the American Society of Anesthesiologists (ASA) grade was established for statistical purposes, it is often used prognostically. However, older patients undergoing elective surgery are typically ASA III, which limits patient stratification. We look at the prognostic effect on early complications and survival of using ASA and self‐reported physical fitness to stratify patients undergoing endovascular repair of abdominal aortic aneurysms.

Mechanisms of Vascular Disease: Pathophysiology of reperfusion injury

Ischaemia-Reperfusion Injury (IRI), which is often referred to as Reperfusion Injury is the tissue damage that occurs following the return of blood flow to ischaemic tissues. Whilst reperfusion is required for tissue/organ viability, the return of oxygen to the tissue induces a complex multi-factorial process involving oxidative stress and inflammatory changes.