1 / 40

Class 5 1 st Year Mestrado Integrado em Medicina

Impact of Risk Factors on Mortality after Elective Open Repair of Abdominal Aortic Aneurysms (AAA):. Class 5 1 st Year Mestrado Integrado em Medicina. Morbidity and Mortality after Elective Open Repair of Abdominal Aortic Aneurysms (AAA): Impact of Risk Factors. Introduction.

jace
Download Presentation

Class 5 1 st Year Mestrado Integrado em Medicina

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Impact of Risk Factors on Mortality after Elective Open Repair of Abdominal Aortic Aneurysms (AAA): Class 51st Year Mestrado Integrado em Medicina

  2. Morbidity and Mortality after Elective Open Repair of Abdominal Aortic Aneurysms (AAA): Impact of Risk Factors

  3. Introduction • Abdominal Aortic Aneurysm (AAA) • 13th cause of death in the US: • 200,000 new diagnosis each year; • 40,000 surgical repairs each year; • 9,000 die from rupture each year. • Risk Factors: • Age>50 y.o. and male gender • Hypertension • Atherosclerosis • Chronic obstructive pulmonary disease • Smoking • Family history of AAA • Previous vascular surgery Morbidity and Mortality after Elective Open Repair of Abdominal Aortic Aneurysms (AAA): Impact of Risk Factors

  4. Introduction • Elective Open Repair (EOR) • “Gold Standard” procedure for AAA repair; • Peri and Postoperative complications • Venous Bleeding/Haemorrhage • Gastrointestinal ischemia and/or dysfunction • Cardiac events (including Myocardial Infarction) • Pulmonary insufficiency • Organ Failure (including Renal failure) • Graft infection • Operative mortality rounds 1% to 5%; Morbidity and Mortality after Elective Open Repair of Abdominal Aortic Aneurysms (AAA): Impact of Risk Factors

  5. Introduction Petr Utikala (2004), Biomed Papers 148(2), 183–187 Morbidity and Mortality after Elective Open Repair of Abdominal Aortic Aneurysms (AAA): Impact of Risk Factors

  6. Morbidity and Mortality after Elective Open Repair of Abdominal Aortic Aneurysms (AAA): Impact of Risk Factors

  7. Research Question and Aims • Research Questions • Which risk factors mostly contribute to mortality after EOR? • Is it possible to improve the prediction of patients’ outcome after EOR? • Aims • Summarize risk factors, postoperative complications and mortality rates of patients with AAA undergoing EOR; • Analyze the impact of risk factors on patients’ outcome after EOR; Morbidity and Mortality after Elective Open Repair of Abdominal Aortic Aneurysms (AAA): Impact of Risk Factors

  8. Morbidity and Mortality after Elective Open Repair of Abdominal Aortic Aneurysms (AAA): Impact of Risk Factors

  9. Participants and Methods • Type of Study • Systematic Review followed by Meta-Analysis • Study Participants • All papers (n=203) published on PubMed Database considering: • "abdominal aortic aneurysm"[Text Word] OR "aortic aneurysm, abdominal"[MeSH Terms] OR aaa[Text Word] • AND elective[All Fields] • AND open[All Fields] • AND ((("wound healing"[TIAB] NOT Medline[SB]) OR "wound healing“[MeSH Terms] OR repair[Text Word]) OR ("surgery"[Subheading] OR "operative surgical procedures"[Text Word] OR "surgical procedures, operative"[MeSH Terms] OR "surgery"[MeSH Terms] OR surgery[Text Word])) • AND mortality[Text Word] Morbidity and Mortality after Elective Open Repair of Abdominal Aortic Aneurysms (AAA): Impact of Risk Factors

  10. Participants and Methods • 1st Triage Step (n=80) • Inclusion Criteria • Abdominal aortic aneurysms (AAA) • Elective open repair/surgery (EOR) • Mortality rates after elective open repair • Postoperative complications • Patient’s outcome • Exclusion Criteria • Other types or “mixed” aortic aneurysms (n=10) • Emergency repair of ruptured AAA (n=13) • Patients submitted to endovascular repair (EVAR) (n=51) • Other papers as reviews, systematic reviews, meta-analysis, letters or editorials (n=20) • Papers in other languages rather than English, French, Spanish or Portuguese (n=16) • Not related studies (n=26) Participants and Methods

  11. Participants and Methods • 2nd Triage Step (n=29+17) • Inclusion Criteria • Full paper available • Provide data about preoperative clinical variables and risk factors • Provide data about postoperative complications • Provide data about patients’ mortality/outcome • Exclusion Criteria • Impossibility to obtain full article by on line request, library acquisition or e-mail request to authors (n=13) • Other types of articles such as, review (n=1) or meeting abstract (n=1) • Not related to the study (n=5) • Absence of data about risk factors (n=10) • Absence of data about mortality (n=4) • Absence of data combining mortality associated to risk factors (n=29) Participants and Methods

  12. Participants and Methods Study Participants • 46 papers (50 individual studies) provided information for Systematic Review: • Clinical variables; • Risk factor exposition; • Postoperative complications; • Outcome. • 17 papers provided Statistical Data for Meta-Analysis: • Risk factor associated Odds Ratio • Risk factor associated Confidence Interval Morbidity and Mortality after Elective Open Repair of Abdominal Aortic Aneurysms (AAA): Impact of Risk Factors

  13. Participants and Methods Variables Selection • Preoperative clinical variables • Age (mean) • Aneurysm Diameter (mean) • Gender (male and female %) • Risk Factors exposition • Smoking Habits (%) • Diabetes Mellitus, DM (%) • History of Cardiac Disease, CDH (%)Myocardial Infarction or coronary disease • Hypertension, HT (%) • History of Pulmonary Disease, PDH (%)COPD or pulmonary embolism • Chronic Renal Failure, CRF (%)Increased Creatinine levels (>1.5 or 2.0mg/dL) • Postoperative Complications • Gastrointestinal Ischemia, GIsch(%) • MultiOrgan Failure, MOF (%) • Renal Failure, RF (%) • Cardiac Complications, CardiacC(%) • Myocardial Infarction, MI (%) • Respiratory Complications, RespC (%) • Total Morbidity Events, (%) • Patients Outcome • Mortality (%) • Risk factor associated outcome • Number of deaths • Number of livings Morbidity and Mortality after Elective Open Repair of Abdominal Aortic Aneurysms (AAA): Impact of Risk Factors

  14. Participants and Methods • Statistical Analysis • Data input on Database using Statistical Package for Social Sciences (SPSS) Version 16.0 used to summarize the mean frequencies, confidence intervals and standard deviations of all clinical variables, risk factors exposition, postoperative complications, and mortality rates; • Epi Info™, Version 6 to perform a χ2 analysis to determine the Odds Ratio (OR) and 95% confidence interval for the association of risk factors influence on patients’ outcome; • R Version 2.6.2 to elaborate the Forest Plot graphics in order to combine the information about the influence of risk factors on patients’ outcome. Morbidity and Mortality after Elective Open Repair of Abdominal Aortic Aneurysms (AAA): Impact of Risk Factors

  15. Morbidity and Mortality after Elective Open Repair of Abdominal Aortic Aneurysms (AAA): Impact of Risk Factors

  16. Results • Systematic Review • Summarize data from 50 individual studies regarding: • Risk Factors • Postoperative complications • Morbidity rates • Mortality rates Morbidity and Mortality after Elective Open Repair of Abdominal Aortic Aneurysms (AAA): Impact of Risk Factors

  17. Results Morbidity and Mortality after Elective Open Repair of Abdominal Aortic Aneurysms (AAA): Impact of Risk Factors

  18. Results • Systematic Review • Major Findings • Median % of Male Gender is 86.9% • Median % of patients with HT is 60.0% • Median % of patients with Smoking habits is 54.2% • Median % of patients with CDH is 44.3% • Median % of Respiratory Complications is 7.5% • Median % of Cardiac Complications is 5.3% • Median occurrence of Morbidity events of 31.0% • Median frequency of Mortality was 4.0% Morbidity and Mortality after Elective Open Repair of Abdominal Aortic Aneurysms (AAA): Impact of Risk Factors

  19. Results • Meta-Analysis • Determine the Odds Ratio (OR) and 95% confidence interval for the influence of risk factors on patients’ outcome: • Mean Age (y.o.) • Mean Aneurysm Diameter (cm) • Gender • Diabetes Mellitus, DM • History of Cardiac Disease, CDH • Hypertension, HT • History of Pulmonary Disease, PDH • Chronic Renal Failure, CRF • Smoking Habits Morbidity and Mortality after Elective Open Repair of Abdominal Aortic Aneurysms (AAA): Impact of Risk Factors

  20. Results Mean Age (per y.o.) Test of heterogeneity: Q: 21.35 d.f.: 7 p.value: 0.003 OR=1.07 95% CI (1.05 – 1.09) p<0.001 0.5 2.0 1.0 5.0 10.0 Morbidity and Mortality after Elective Open Repair of Abdominal Aortic Aneurysms (AAA): Impact of Risk Factors

  21. Results Mean Aneurysm Diameter (per cm) Test of heterogeneity: Q: 0.19 d.f.: 2 p.value: 0.910 OR=1.58 95% CI (1.11 – 2.25) p=0.011 1.0 0.5 2.0 Morbidity and Mortality after Elective Open Repair of Abdominal Aortic Aneurysms (AAA): Impact of Risk Factors

  22. Results Female Gender Test of heterogeneity Q: 4.87 d.f.: 7 p.value: 0.676 OR=1.58 95% CI (1.39 – 1.80) p<0.001 1.0 0.2 0.5 2.0 5.0 10.0 20.0 Morbidity and Mortality after Elective Open Repair of Abdominal Aortic Aneurysms (AAA): Impact of Risk Factors

  23. Results Diabetes Mellitus Test of heterogeneity Q: 1.24 d.f.: 3 p.value: 0.744 OR=1.28 95% CI (0.80 – 2.06) p=0.309 0.5 2.0 20.0 1.0 5.0 10.0 Morbidity and Mortality after Elective Open Repair of Abdominal Aortic Aneurysms (AAA): Impact of Risk Factors

  24. Results Cardiac Disease History (CDH) Test of heterogeneity Q: 20 d.f.: 6 p.value: 0.003 OR=1.93 95% CI (1.42 – 2.62) p<0.001 0.05 0.1 1.0 50.0 0.2 0.5 2.0 5.0 20.0 Morbidity and Mortality after Elective Open Repair of Abdominal Aortic Aneurysms (AAA): Impact of Risk Factors

  25. Results Hypertension (HT) Test of heterogeneity Q: 51.04 d.f.: 5 p.value: <0.001 OR=2.95 95% CI (2.14 – 4.05) p<0.001 0.05 0.1 1.0 50.0 0.2 0.5 2.0 5.0 10.0 20.0 Morbidity and Mortality after Elective Open Repair of Abdominal Aortic Aneurysms (AAA): Impact of Risk Factors

  26. Results Pulmonary Disease History (PDH) Test of heterogeneity Q: 6.26 d.f.: 6 p.value: 0.394 OR=1.32 95% CI (0.94 – 1.87) p=0.112 0.1 1.0 0.2 0.5 2.0 5.0 10.0 Morbidity and Mortality after Elective Open Repair of Abdominal Aortic Aneurysms (AAA): Impact of Risk Factors

  27. Results Chronic Renal Failure (CRF) Test of heterogeneity Q: 9.29 d.f.: 7 p.value: 0.232 OR=2.78 95% CI (2.21 – 3.47) p<0.001 20.0 0.5 1.0 2.0 5.0 10.0 50.0 100.0 Morbidity and Mortality after Elective Open Repair of Abdominal Aortic Aneurysms (AAA): Impact of Risk Factors

  28. Results Smoking Habits (current smoker) Test of heterogeneity Q: 4.29 d.f.: 4 p.value: 0.368 OR=1.00 95% CI (0.99 – 1.01) p=0.987 0.05 2.0 0.5 0.1 0.2 1.0 5.0 Morbidity and Mortality after Elective Open Repair of Abdominal Aortic Aneurysms (AAA): Impact of Risk Factors

  29. Results • Meta-Analysis • Influence of risk factor in patient’s outcome after EOR: • Hypertension (OR=2.95; p<0.001) • Chronic Renal Failure (OR=2.78; p<0.001) • Cardiac Disease History (OR=1.93; p<0.001) • Female Gender (OR=1.58; p<0.001) • Aneurysm Diameter (OR=1.58; p=0.011) • Pulmonary Disease History (OR=1.32; p=0.112) • Diabetes Mellitus (OR=1.28; p=0.309) • Mean Age (OR=1.07; p<0.001) • Smoking (OR=1.00; p=0.987) Morbidity and Mortality after Elective Open Repair of Abdominal Aortic Aneurysms (AAA): Impact of Risk Factors

  30. Morbidity and Mortality after Elective Open Repair of Abdominal Aortic Aneurysms (AAA): Impact of Risk Factors

  31. Discussion • Limitations related to study design: • Search only in ONE online Database (PubMed). • Limitations related to the query: • Absence of a unique MeSh term to define “elective open repair”; • The “huge” number of risk factors and postoperative complications; • Difficulty to define the outcome as <30 days after surgery. • Limitations related to studies: • Heterogeneity of the studies; • Absence of data relative to the most common risk factors; • Absence of data relative to risk factors associated outcome. Morbidity and Mortality after Elective Open Repair of Abdominal Aortic Aneurysms (AAA): Impact of Risk Factors

  32. Discussion • Epidemiological Data • Systematic review revealed: • Increased frequency of Male Gender (median 86.9%); • Patients are diagnosed with advanced age (median 71.0 y.o); • Increased Aneurism Diameter (median 5.9 cm); • Our results show similar distribution to those shown in literature referring that AAA are more common in men with age ranging 65-75 y.o. and diagnosed with a diameter of the aorta below the renal arteries of >3.0 cm. Moreover, only patients with AAA >5.0cm are usually indicated for surgical repair. • Gillum RF. J ClinEpidemiol. 1995 Nov;48(11):1289-98.Flemming C, et al. Ann. Intern. Med. 142 (3): 203-11. Lederle FA, et al. Arch Intern Med. 2000;160:1425-30. Morbidity and Mortality after Elective Open Repair of Abdominal Aortic Aneurysms (AAA): Impact of Risk Factors

  33. Discussion • Risk Factors • The most common risk factors found were: • Male Gender (median 86.9%); • Advanced age (median 71.0 y.o); • History of Hypertension, HT (median 60.0%) • Smoking Habits (median 54.1%) • History of Cardiac Diseases, CDH (median 44.3%) • The great majority of studies, including the “ACC/AHA 2005 guidelines”refer age, smoking, and gender as the most significant AAA risk factors, although, hypertension and history of cardiac disease are also considered • Cornuz J, et al. Eur J Public Health 2004; 14(4):343-349.Lederle FA, et al. Arch Intern Med 2000;160:1425-30. Hirsch AT, et al. J Am CollCardiol2006 Mar 21;47(6):1239-312 Morbidity and Mortality after Elective Open Repair of Abdominal Aortic Aneurysms (AAA): Impact of Risk Factors

  34. Discussion • Morbidity/Postoperative Complications • The median occurrence of Morbidity events was of 31.0%, and the most frequent postoperative complications found were: • Respiratory Complications (median 7.5%) • Cardiac Complications (median 5.7%) • There is a wide variety of postoperative complications, and most of them are correlated with the healthy condition of the patient prior to the surgery, or also to the experience of the surgical team. Nevertheless, it is accepted that between 5-25% of all patients will at least suffer one complication. • Hirsch AT, et al. J Am CollCardiol2006 Mar 21;47(6):1239-312Wilt TJ, et al.Evid Rep Technol Assess (Full Rep). 2006 Aug;(144):1-113. Morbidity and Mortality after Elective Open Repair of Abdominal Aortic Aneurysms (AAA): Impact of Risk Factors

  35. Discussion Mortality The median frequency of Mortality found was 4.0%. Mortality rates <30days after surgery for patients undergoing EOR ranges between 1-5%, although in some surgical teams this can be 0%. Despite the differential conditions of patients, in-hospital care conditions are extremely important to prevent higher mortality rates. Hirsch AT, et al. J Am CollCardiol2006 Mar 21;47(6):1239-312 Moreover, mortality rates seem to be influenced by patients’ risk factor exposition and therefore can vary within studies. Lederle FA, et al. Arch Intern Med. 2000;160:1425-30. Morbidity and Mortality after Elective Open Repair of Abdominal Aortic Aneurysms (AAA): Impact of Risk Factors

  36. Discussion Influence of risk factor in patient’s outcome after EOR Smoking is considered a significant risk marker for AAA development, although, statistical analysis revealed that it did not influence patient’s outcome. Despite statistical analysis did not provide significant data, Pulmonary Disease History and Diabetes Mellitus may influence the outcome since they represent an increase of 32% and 28%, respectively, in the risk for death after EOR.Nevertheless, these two risk factors require more studies to clarify its effect on patients’ outcome. Morbidity and Mortality after Elective Open Repair of Abdominal Aortic Aneurysms (AAA): Impact of Risk Factors

  37. Discussion Influence of risk factor in patient’s outcome after EOR Statistical analysis revealed that Hypertension or Chronic Renal Failure represent an almost 3-folds increased risk for death after EOR. These risk factors are strictly correlated with patients’ health condition and are extremely important in the recovery after any surgical procedure. As expected Cardiac Disease represent an increased risk factor for death after EOR (almost 2-folds), since it is common that people who suffered cardiac events may have repetitions shortly in time. Morbidity and Mortality after Elective Open Repair of Abdominal Aortic Aneurysms (AAA): Impact of Risk Factors

  38. Discussion Influence of risk factor in patient’s outcome after EOR Remarkably interesting is the fact that Female Gender revealed a 58% increase risk of death after EOR. Although, male gender is a risk factor, when a female develop AAA it has, usually, more severe consequences and death can occur shortly after surgery. Statistical analysis also revealed that an increment of 1cm of the Aneurysm Diameter represents a 58% increase risk of death after EOR. Age has also proved to influence the risk of death after EOR, with an increment of 7% per year. Morbidity and Mortality after Elective Open Repair of Abdominal Aortic Aneurysms (AAA): Impact of Risk Factors

  39. Discussion Despite the fact that EOR has been substituted by Endovascular Repair, EOR has proven to have good results in AAA management, but may require experienced surgeons and good in-hospital intensive care units in order to contribute for the improvement of AAA management. El SK, et al. Interact Cardiovasc Thorac Surg 2008; 7(1):121-124. Our study revealed important findings that contribute to the prediction of patient’s outcome after EOR, by simple analysis of risk factor exposition. Moreover, it may allow the development of a decision tree for the selection of patients that can be submitted to EOR and expect a good outcome. Morbidity and Mortality after Elective Open Repair of Abdominal Aortic Aneurysms (AAA): Impact of Risk Factors

  40. Impact of Risk Factors on Mortality after Elective Open Repair of Abdominal Aortic Aneurysms (AAA): Class 51st Year Mestrado Integrado em Medicina

More Related