Factors associated with in-hospital complications and long-term implications of these complications in elderly patients undergoing endovascular aneurysm repair.

Autor:	Varkevisser RRB; Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass; Department of Vascular Surgery, Erasmus University Medical Center Rotterdam, the Netherlands., O'Donnell TFX; Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass; Department of Surgery, Massachusetts General Hospital, Boston, Mass., Swerdlow NJ; Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass., Liang P; Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass., Li C; Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass., Ultee KHJ; Department of Vascular Surgery, Erasmus University Medical Center Rotterdam, the Netherlands., Patel VI; Section of Vascular Surgery, New York-Presbyterian/Columbia University Irving Medical Center/Columbia University Vagelos College of Physicians & Surgeons, New York, NY., Scali ST; Division of Vascular Surgery and Endovascular Therapy, University of Florida Health, Gainesville, Fla., Verhagen HJM; Department of Vascular Surgery, Erasmus University Medical Center Rotterdam, the Netherlands., Schermerhorn ML; Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass. Electronic address: mscherm@bidmc.harvard.edu.
Jazyk:	angličtina
Zdroj:	Journal of vascular surgery [J Vasc Surg] 2020 Feb; Vol. 71 (2), pp. 470-480.e1. Date of Electronic Publication: 2019 Jun 24.
DOI:	10.1016/j.jvs.2019.03.059
Abstrakt:	Objective: Perioperative complications in elderly patients undergoing endovascular aneurysm repair (EVAR) occur frequently. Although perioperative mortality has been well-described in the elderly patient population, factors associated with in-hospital complications and their impact on long-term survival remain poorly characterized. Methods: We identified all patients undergoing elective EVAR for infrarenal AAA within the Vascular Quality Initiative registry (2003-2018) and compared in-hospital complication rates between elderly (age ≥75) and nonelderly patients (<75). We used logistic regression to identify independent factors associated with in-hospital complications, whereas Kaplan-Meier analysis and Cox proportional hazards models were used to determine associations between complications and long-term survival. To assess the effect of complications on early and late survival, we stratified survival periods into the first 30 days after discharge, and between 1 and 6 months, 7 and 12 months, and 1 and 8 years after the index procedure. To investigate the implications of in-hospital morbidity on long-term outcomes, we estimated the adjusted population-attributable fractions of individual complications on both perioperative and long-term survival. Results: We identified 17,156 elderly patients and 19,922 nonelderly patients. Elderly patients experienced higher complication rates compared with nonelderly patients (17% vs 10%; P < .001). The factors with the strongest associations with morbidity in elderly patients were anemia (odds ratio [OR], 2.4; 95% confidence interval [CI], 2.2-2.6), female gender (OR, 1.9; 95% CI, 1.7-2.1), and large AAA diameter (OR, 1.7; 95% CI, 1.6-1.9). Patients with any in-hospital complication had lower unadjusted survival estimates than patients without complications at 1 year (83% vs 95%; P < .001), 5 years (66% vs 80%; P < .001), and 8 years (60% vs 72%; P < .001). After risk adjustment, in-hospital complications were independently associated with higher mortality, although the association attenuated over time (first month after discharge: hazard ratio [HR], 5.9; 95% CI, 3.9-9.1; 1-6 months after the procedure: HR, 2.1; 95% CI, 1.7-2.7; P < .001; 7-12 months after the procedure: HR, 1.5; 95% CI, 1.1-1.9; 1-8 years after the procedure: HR, 1.2; 95% CI, 1.01-1.3). Of all deaths occurring within 8 years after procedure, 9.5% were independently associated with in-hospital complications. Complications with the greatest impact on long-term mortality were renal dysfunction (2.4%), blood transfusion (3.4%), and reintubations (2.4%). Conclusions: Elderly patients are at higher risk for in-hospital complications after EVAR. These in-hospital complications have a significant impact on both short- and long-term survival. To further improve the delivery of EVAR care nationally, quality improvement efforts should be focused on preventing postoperative morbidity in elderly patients, as well as refining out of hospital surveillance strategies for subjects who experience in-hospital complications to improve overall survival. (Copyright © 2019 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)
Databáze:	MEDLINE
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