Search

We investigated the yield of ultrasound surveillance for small abdominal aortic aneurysms (AAAs) in patients older than 80 years compared with a younger population for detecting AAA growth reaching the threshold size for repair. Secondary objectives included analysis of the incidence of AAA repair and the cost-benefit of surveillance.A retrospective cohort study was performed of all patients undergoing AAA surveillance in Ottawa between 2007 and 2015. Patients were dichotomized by enrollment age (80 years vs ≥80 years) and stratified by enrollment AAA size. Cohorts were cross-referenced with the Ottawa surgical database, leveraging the common health region to ensure complete data capture. The threshold size for repair was sex specific (female, 5.0 cm; male, 5.5 cm). Factors influencing AAA growth rate were assessed with a general linear multiple mixed model. Analyses with Cox proportional hazards models with competing risk for mortality assessed aorta-related events, and cost-benefit was analyzed by referencing Ontario billing codes.A total of 1231 patients underwent serial ultrasound surveillance, of whom 500 were older than 80 years at some point during the study period. The mean AAA growth rate was 1.63 mm/y (95% confidence interval [CI], 1.54-1.71). Old age and small enrollment aneurysm size were significantly protective against AAA growth. Overall, 357 (29%) patients reached the AAA size threshold for repair, and 272 (22%) underwent AAA repair. Patients older than 80 years were less likely to reach the AAA threshold size for repair compared with their younger counterparts (adjusted hazard ratio, 0.77; 95% CI, 0.61-0.97). Of the 357 patients whose AAA reached the threshold size for repair, octogenarians were substantially less likely to undergo elective AAA repair (adjusted hazard ratio, 0.34; 95% CI, 0.24-0.47). Repair of ruptured AAA was rare (0.8%), and age differences were insignificant. For every octogenarian with an enrollment AAA size between 3.0 and 3.9 cm who ultimately received elective AAA repair, 51 patients were enrolled in surveillance without elective repair. This corresponded to an estimated $33,139 in ultrasound fees.Surveillance of most patients with small AAA is appropriate. However, patients older than 80 years were significantly less likely than their younger counterparts to experience aortic growth reaching the threshold size for repair. Furthermore, in the unlikely event of AAA growth, patients older than 80 years were substantially less likely to undergo repair. These results suggest that in the context of patient-specific health and wishes, surveillance of AAAs 4 cm in octogenarians is costly and unlikely to be beneficial.

Objectives Patients with infrainguinal peripheral arterial disease often undergo multiple revascularisation procedures. Although many centres have adopted an endovascular first approach, some are reluctant to do so for fear of compromising the outcomes of any subsequent bypasses. All studies that compared the outcomes of primary infrainguinal bypass with bypass after failed endovascular intervention were analysed. Methods A systematic review was conducted of MEDLINE, EMBASE, and CENTRAL databases for studies comparing outcomes of primary infrainguinal bypass with bypass after failed endovascular intervention for peripheral arterial disease. Abstracts and full text studies were screened independently by two reviewers with data abstraction done in duplicate. Dichotomous outcome measures were reported using the OR and 95% CI, and pooled using random effects models. Results Abstracts were screened (2,528), with 50 selected for full text review. Of these, 15 studies involving 11,886 patients met the inclusion criteria. Pooling the results of studies comparing primary bypass with bypass after failed endovascular intervention showed no significant difference in 30 day mortality (OR 1.00; 95% CI 0.65–1.54), or 30 day amputation rates (OR 1.26; 95% CI 0.95–1.65). Interestingly, one year amputation free survival was higher in the patients who had primary bypass (OR 1.30; 95% CI 1.10–1.52) compared with patients who had bypass after failed endovascular therapy. There was also worse one year primary patency (OR 1.65; 95% CI 1.04–2.62) for patients with prior failed endovascular intervention. The review demonstrated a trend towards higher rates of early graft occlusion (OR 4.54; 95% CI 0.97–21.28). Conclusions Meta-analysis of the existing literature comparing primary bypass with bypass following failed endovascular intervention shows worse one year amputation free survival and worse primary patency in those patients who undergo bypass after failed endovascular intervention. There is also a trend towards higher rates of early graft occlusion, although these results were not statistically significant. These conclusions are limited by observational study design, inconsistent patient selection, and significant heterogeneity between studies.

Objective Patient-based decision aids and other multimedia tools have been developed to help enrich the preoperative discussion between surgeon and patient. Use of these tools, however, can be time-consuming and logistically challenging. We investigated whether simply showing patients their images from preoperative computed tomography (CT) or angiography would improve patients' satisfaction with the preoperative discussion. We also examined whether this improved the patient's understanding and trust and whether it contributed to increased preoperative anxiety. Methods Patients undergoing either elective abdominal aortic aneurysm repair or lower limb revascularization were randomly assigned to either standard perioperative discussion or perioperative discussion and review of images (CT image or angiogram). Randomization was concealed and stratified by surgeon. Primary outcome was patient satisfaction with the preoperative discussion as measured by a validated 7-item scale (score, 0-28), with higher scores indicating improved satisfaction. Secondary outcomes included patient understanding, patient anxiety, patient trust, and length of preoperative discussion. Scores were compared using t-test. Results Overall, 51 patients were randomized, 25 to the intervention arm (discussion and imaging) and 26 to the control arm. Most patients were male (69%), and the average age was 70 years. Forty percent of patients underwent abdominal aortic aneurysm repair, whereas 60% underwent lower limb revascularization. Patient satisfaction with the discussion was generally high, with no added improvement when preoperative images were reviewed (mean score, 24.9 ± 3.02 vs 24.8 ± 2.93; P = .88). Similarly, there was no difference in the patient's anxiety, level of trust, or understanding when the imaging review was compared with standard discussion. There was a trend toward longer preoperative discussions in the group that underwent imaging review (8.18 vs 6.35 minutes; P = .07). Conclusions Showing patients their CT or angiography images during the preoperative discussion does not improve the patient's satisfaction with the consent discussion. Similarly, there was no effect on the patient's trust, understanding, or anxiety level. Our conclusions are limited by the lack of a standardized measure of patient understanding and not measuring outcomes postoperatively, both of which should be considered in future studies.