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Extracorporeal bypass use improves outcomes of open thoracic and thoracoabdominal aneurysm repair
Virendra I. Patel, MD, MPH, Shankha Mukhopadhyay, MS, Emel Ergul, MS, Mark F. Conrad, MD MSSc, Richard P. Cambria, MD.
Massachusetts General Hospital, Boston, MA, USA.
Objective: There is no consensus on the use and/or benefit of extracorporeal circulation (EC) during descending thoracic (DTA) and/or thoracoabdominal (TAA) aneurysm repair. We evaluated the role of EC during DTA or TAA repair using US Medicare data.
Methods: Medicare (2004-2007) patients undergoing intact open DTA or TAA repair were identified by ICD-9 code; specific exclusions included ascending/arch and hypothermic circulatory arrest (DHCA) operations. The impact of EC (ICD-9: 39.61) on early and late outcomes was analyzed using standard statistical methods.
Results: 4230 patients had DTA or TAA repair with EC used in 2433 (57%). Differences in baseline clinical features are presented in Table 1. 30 day mortality, any complication, and systemic complications were significantly reduced with EC use (Table 1). EC patients had shorter LOS (13.5±13days (EC) vs.17.2±18; P<0.01) and lower total hospital charges ($151K±140K (EC) vs. $180K±190K; P<0.01). EC patients were more likely to be discharged home vs. an extended care facility (67 % ( EC) vs. 56%; P<0.01). Multivariable regression modeling to adjust for baseline clinical differences showed EC to independently reduce operative mortality (OR 0.80[95%CI: 0.65–0.97]; P=0.02), any complication (OR 0.67[95%CI: 0.59–0.76]; P<0.01), pulmonary complications (OR 0.68[95%CI: 0.59–0.79]; P<0.01), and acute renal failure (OR 0.52[95%CI: 0.44–0.61]; P<0.01). Long term survival was higher (Log rank P<0.01) in EC patients at 1 (81±0.8 %( EC) vs.73±1), and 5 yrs. (67±1 %( EC) vs.52±1). Risk adjusted Cox proportional hazards regression also showed that EC was independently associated with improved long-term survival (OR 0.69[95%CI: 0.63–0.74]; P<0.01).
Conclusion: Although important clinical variables such as DTA/TAA extent and spinal cord ischemic complications cannot be assessed with the Medicare database, EC used during open DTA and TAA repair significantly reduces operative mortality, morbidity, procedural costs, and improves late survival. These data indicate EC should be a more widely applied adjunct in DTA/TAA open surgery.
Table 1. Univariate differences in clinical features & outcomes following DTA/TAA repair | | | | | Extracorporeal Bypass (EC)
N=2433 | No Bypass
(clamp/sew)
N=1797 | P Value | | Clinical features | | | | | Age | 73±7.6 yrs | 71.7±8 | <0.01 | | Female gender | 52% | 48% | <0.01 | | CAD | 23% | 24% | 0.7 | | COPD | 28% | 34% | <0.01 | | PVD | 5.7% | 11.3% | <0.01 | | CKD | 5.5% | 7.7% | <0.01 | | | | | | Outcomes | | | | | 30-day Mortality | 9.7% | 12.2% | <0.01 | | Any complication | 49% | 58% | <0.01 | | Cardiac comp. | 14% | 13% | 0.16 | | Pulmonary comp. | 21% | 27% | <0.01 | | Acute renal failure | 14% | 24% | <0.01 | | Bleeding comp. | 13% | 19% | <0.01 | | Infectious comp. | 5.9% | 7.7% | <0.01 |
CAD=coronary artery disease, COPD=chronic obstructive pulmonary disease, PVD=peripheral vascular disease, CKD=chronic kidney disease
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