title: Performance of endovascular aortic aneurysm repair in high-risk patients: results from the Veterans Affairs National Surgical Quality Improvement Program.
abstract: OBJECTIVE
  Recent results after endovascular abdominal aortic aneurysm repair (EVAR) have brought into question its value in patients deemed at high-risk for surgical intervention. The Department of Veteran Affairs (VA) National Surgical Quality Improvement Program (NSQIP) is the largest prospectively collected and validated United States surgical database representing current clinical practice. The purpose of our study was to evaluate outcomes after elective EVAR performed in high-risk veterans.
  
  
  METHODS
  Using NSQIP data from 123 participating VA hospitals, we retrospectively evaluated patients who underwent elective aneurysm repair from May 2001 to December 2004. High-risk criteria were used to identify a cohort for analysis (EVAR, n = 788; open, n = 1580). High-risk criteria analyzed included age > or =60 years, American Society of Anesthesiology (ASA) classification 3 or 4, and the comorbidity variables of history of cardiac, respiratory, or hepatic disease, cardiac revascularization, renal insufficiency, and low serum albumin level. Our primary end points were 30-day and 1-year all-cause mortality, and we evaluated a secondary end point of perioperative complications. Statistical analysis included univariate analysis and multivariate modeling.
  
  
  RESULTS
  Veterans who were classified as high-risk underwent elective EVAR with significantly lower 30-day (3.4% vs 5.2%, P = .047) and 1-year all-cause mortality (9.5% vs 12.4%, P = .038) than patients having open repair. EVAR was associated with a decrease in 30-day postoperative mortality (adjusted odds ratio [OR], 0.65; 95% confidence interval [CI], 0.42 to 1.03; P = .067) as well as 1-year mortality (adjusted OR, 0.68; 95% CI, 0.51 to 0.91; P = .0094) despite the presence of severe comorbid conditions. The risk of perioperative complications was significantly lower after EVAR (16.2% vs 31.0%; P < .0001; adjusted OR, 0.41; 95% CI, 0.33 to 0.52; P < .0001). A subset analysis of higher-risk patients (ASA 4 and the above comorbidity variables) still demonstrated an acceptable 30-day mortality rate.
  
  
  CONCLUSIONS
  In veterans deemed high-risk for surgical therapy, outcomes after elective EVAR are excellent, and the procedure is relatively safe in this special patient population. Our retrospective data demonstrate that patients with considerable medical comorbidities and infrarenal abdominal aortic aneurysms benefit from and should be considered for primary EVAR.
authors.affiliation: Michael E. DeBakey Department of Surgery, Baylor College of Medicine, the University of Houston, College of Pharmacy, Houston, TX 77030, USA. rbush@bcm.tmc.edu
authors.forename: Ruth L
authors.initials: RL
authors.lastname: Bush
authors.forename: Michael L
authors.initials: ML
authors.lastname: Johnson
authors.forename: Nasim
authors.initials: N
authors.lastname: Hedayati
authors.forename: William G
authors.initials: WG
authors.lastname: Henderson
authors.forename: Peter H
authors.initials: PH
authors.lastname: Lin
authors.forename: Alan B
authors.initials: AB
authors.lastname: Lumsden
mesh_terms: D000368:Aged; D017130:Angioplasty / Q000009:adverse effects; D017544:Aortic Aneurysm, Abdominal / Q000401:mortality / Q000601:surgery*; D015331:Cohort Studies; D017558:Elective Surgical Procedures; D005260:Female; D006787:Hospitals, Veterans; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D018579:Patient Selection; D011446:Prospective Studies; D011785:Quality Assurance, Health Care; D012189:Retrospective Studies; D018570:Risk Assessment; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States; D014493:United States Department of Veterans Affairs; D014656:Vascular Surgical Procedures / Q000009:adverse effects