title: Complication profile, failure to rescue, and mortality following elective endovascular aortic aneurysm repair.
abstract: BACKGROUND
  Understanding the relationship between patient risk factors, postoperative complications, and morbidity and mortality is important when considering elective endovascular aortic aneurysm repair (E-EVAR) performed to prevent aneurysm rupture mortality. We aimed to stratify complications in E-EVAR and explore their relationship with postoperative death.
  
  
  METHODS
  E-EVAR cases from 2012 NSQIP were identified. 30-day complications were categorized as major (MAJCX) or minor (MINCX) using the Clavien-Dindo classification. Failure to rescue (FTR) was defined as death following a complication. Univariate and multivariate analyses were performed to identify associations between patient risk factors, complications, and mortality. Significance set at P < 0.05.
  
  
  RESULTS
  3344 E-EVAR's were analyzed, with 155 (4.6%) MINCX, 106 (3.2%) MAJCX, and 39 (1.2%) mortality. Significant univariate risk factors differed between MINCX (preoperative dyspnea 27% vs 19%, COPD 32% vs19%, HTN 87% vs 79%, functional dependence 9% vs 3%) and MAJCX (female sex 33% vs 18%, preoperative diabetes 30% vs 17%, dyspnea 40% vs 19%, COPD 46% vs 20%, anticoagulant use 20% vs 11%, and functional dependence 13% vs 3%). 24 of 39 (62%) of deaths were preceded by a complication. FTR was more frequent following MAJCX than MINCX (16% vs 4.5%, P = 0.002), and occurred most commonly after renal failure with dialysis (33% mortality with complication), cardiac arrest (33%), septic shock (22%), and reintubation (22%). Independent predictors of MAJCX included female sex (OR 2, P = 0.001), COPD (OR 2, P = 0.009), and anticoagulant use (OR 2, P = 0.001). Mortality was independently predicted by MAJCX (OR 29, P < 0.001), MINCX (OR 8, P < 0.001), and preoperative renal failure (OR 11.6, P < 0.001).
  
  
  CONCLUSIONS
  The majority of deaths within 30 days following E-EVAR are preceded by a complication; both MAJCX and MINCX predict mortality. FTR is more common after MAJCX; prevention efforts should take this into account. Identified risk factors should be taken into consideration when considering E-EVAR.
authors.affiliation: Vascular Surgery Service, Dwight D. Eisenhower Army Medical Center, Ft. Gordon, GA, USA; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, USA. Electronic address: davekauvar@gmail.com.
authors.forename: David S
authors.initials: DS
authors.lastname: Kauvar
authors.affiliation: Vascular Surgery Service, Dwight D. Eisenhower Army Medical Center, Ft. Gordon, GA, USA.
authors.forename: Eric D
authors.initials: ED
authors.lastname: Martin
authors.affiliation: Vascular Surgery Service, Dwight D. Eisenhower Army Medical Center, Ft. Gordon, GA, USA.
authors.forename: Todd E
authors.initials: TE
authors.lastname: Simon
authors.affiliation: Department of Radiology, Dwight D. Eisenhower Army Medical Center, Ft. Gordon, GA, USA.
authors.forename: Matthew D
authors.initials: MD
authors.lastname: Givens
mesh_terms: D000368:Aged; D017544:Aortic Aneurysm, Abdominal / Q000401:mortality* / Q000601:surgery*; D017558:Elective Surgical Procedures; D057510:Endovascular Procedures; D000067248:Failure to Rescue, Health Care / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D008297:Male; D011183:Postoperative Complications / Q000453:epidemiology*; D012307:Risk Factors