Racial and sex disparities in inpatient outcomes of patients with ruptured abdominal aortic aneurysms in the United States.

BACKGROUND: Ruptured abdominal aortic aneurysm (AAA) is a medical emergency that requires immediate surgical intervention. The aim of this analysis was to identify the sex- and race-specific disparities that exist in outcomes of patients hospitalized with this condition in the United States using the National Inpatient Sample (NIS) to identify targets for improvement and support of specific patient populations. METHODS: In this descriptive, retrospective study, we analyzed the patients admitted with a primary diagnosis of ruptured AAA between January 1, 2016, and December 31, 2020, using the NIS database. We compared demographics, comorbidities, and in-hospital outcomes in AAA patients, and compared these results between different racial groups and sexes. RESULTS: A total of 22,395 patients with ruptured AAA were included for analysis. Of these, 16,125 patients (72.0%) were male, and 6270 were female (28.0%). The majority of patients (18,655 [83.3%]) identified as Caucasian, with the remaining patients identifying as African American (1555 [6.9%]), Hispanic (1095 [4.9%]), Asian or Pacific Islander (470 [2.1%]), or Native American (80 [0.5%]). Females had a higher risk of mortality than males (OR, 1.7; 95% confidence interval [CI], 1.45-1.96; P < .001) and were less likely to undergo endovascular aortic repair (OR, 0.70; 95% CI, 0.61-0.81; P < .001) or fenestrated endovascular aortic repair (OR, 0.71; 95% CI, 0.55-0.91; P = .007). Relative to Caucasian race, patients who identified as African American had a lower risk of inpatient mortality (OR, 0.50; 95% CI, 0.37-0.68; P < .001). CONCLUSIONS: In this retrospective study of the NIS database from 2016 to 2020, females were less likely to undergo endovascular intervention and more likely to die during their initial hospitalization. African American patients had lower rates in-hospital mortality than Caucasian patients, despite a higher burden of comorbidities. Future studies are needed to elucidate the potential factors affecting racial and sex disparities in ruptured AAA outcomes, including screening practices, rupture risk stratification, and more personalized guidelines for both elective and emergent intervention.

Morphologic Features of Symptomatic and Ruptured Abdominal Aortic Aneurysm in Asian Patients.

BACKGROUND: To evaluate morphologic features of symptomatic and ruptured abdominal aortic aneurysms in Asian patients. METHODS: Two hundred sixty four continuous candidates with an abdominal aortic aneurysm (AAA) were retrospectively identified from a tertiary hospital database between January 2017 and May 2019. The patients meeting inclusion criteria were divided into symptomatic or ruptured AAA (srAAA) and asymptomatic AAA (asAAA) groups. Their computed tomography angiographies were reconstructed using centerline technique and the geometric features of AAAs between the 2 groups were compared. RESULTS: One hundred two patients fulfilled selection criteria (mean age 71 years, 80 men), comprising 35 srAAAs and 67 asAAAs. There was no essential association between gender, smoking or hypertension, and AAA-associated symptoms or rupture. The maximum diameter (5.8 ± 1.4 cm vs. 5.0 ± 0.9 cm; P = 0.001), length (8.8 ± 0.6 cm vs. 7.0 ± 0.3 cm; P = 0.002), and intraluminal thrombus (ILT) thickness (1.7 ± 0.2 cm vs. 1.3 ± 0.1 cm; P = 0.039) of AAAs were independent risk factors for AAA-associated symptoms or rupture (binary logistic regression, P < 0.05), but AAA length and ILT were strongly correlated with the AAA diameter (Pearson correlation coefficient value of 0.591 and 0.444) whereas other factors such as aneurysmal tortuosity, aneurysmal neck anatomy, or common iliac artery geometry were nonsignificant. CONCLUSIONS: AAA diameter, length, and intraluminal thrombus thickness were identified as risk factors for AAA-associated symptoms in Asian patients. While the diameter is regarded as the most important predictor for symptoms and rupture, AAA length and ILT thickness should also be taken into consideration when contemplating intervention, particularly for borderline and smaller aneurysms.

Advanced complicated diabetes mellitus is associated with a reduced risk of thoracic and abdominal aortic aneurysm rupture: a population-based cohort study.

BACKGROUND: Studies have associated diabetes mellitus (DM) with the reduced risk of abdominal aortic aneurysm and thoracic aortic aneurysm and dissection. We used the national insurance data of Taiwan to examine these correlations for an Asian population. The association was also evaluated by DM severity. METHODS: We identified 160,391 patients with type 2 DM diagnosed from 1998 to 2008 and 646,710 comparison subjects without DM, frequency matched by diagnosis date, sex and age (mainly the elderly). The DM severity was partitioned into advanced and uncomplicated status according to DM-related comorbidities. RESULTS: By the end of 2010, the overall pooled incidence rate of thoracic aortic aneurysm and abdominal aortic aneurysm was 15% lower in the type 2 DM cohort than in non-DM cohort, with an adjusted hazard ratio of 0.64 [95% confidence interval (CI) 0.56-0.74] in the multivariable Cox model. Patients with advanced type 2 DM were significantly associated with reduced thoracic aortic aneurysm rupture and abdominal aortic aneurysm without rupture, with adjusted hazard ratios of 0.50 (95% CI 0.35-0.71) and 0.53 (95% CI 0.40-0.69), respectively. Uncomplicated type 2 DM was also associated with reduced abdominal aortic aneurysm without rapture (aHR = 0.58, 95% CI 0.45-0.74). CONCLUSIONS: Our results demonstrate that patients with diabetes in this Asian population have reduced prevalence of thoracic and abdominal aortic aneurysms. The observed paradoxical inverse relationship between severity of DM and aortic aneurysms is clear. Further research is required to investigate the underlying mechanisms for the reduced risk of aortic aneurysms associated with diabetes.

Predictors of mortality after emergency or elective repair of abdominal aortic aneurysm in a Japanese population.

In Japan, there has been virtually no study in a population large enough to definitively demonstrate a relationship between the preoperative clinical features and postoperative outcomes in patients undergoing abdominal aortic aneurysm (AAA) repair. The aim of this study was to determine the preoperative variables that significantly predict postoperative mortality after emergency or elective repair in Japanese patients with infrarenal AAA. In this retrospective cohort study, we assessed significant predictors of postoperative mortality in 1055 consecutive patients undergoing emergency (n = 186) or elective repair (n = 869) of an infrarenal AAA at the University of Tokyo Hospital or Sakakibara Heart Institute (Tokyo, Japan). Using logistic regression analysis, anemia (hemoglobin <9 g/dl), shock (systolic blood pressure <80 mmHg), and hypocholesterolemia (total cholesterol <120 mg/dl) were found to be independent preoperative predictors of 30-day mortality after emergency repair for ruptured AAA. The hazard ratio (HR) (95 % confidence interval) for these three predictors was 5.96 (1.70-20.84), 8.48 (1.47-49.02), and 7.31 (1.96-27.35), respectively. In the elective repair cases, no significant preoperative predictor of postoperative mortality could be identified either within or beyond 30 days of surgery. Hypocholesterolemia, anemia, and shock were found to be independent preoperative predictors of a postoperative high mortality rate in Japanese patients undergoing emergency repair for ruptured infrarenal AAA.

Outcomes following endovascular or open repair for ruptured abdominal aortic aneurysm in a Chinese population.

To determine whether emergent endovascular repair (eEVAR) can be an alternative for anatomically suitable ruptured abdominal aortic aneurysms (RAAA) in a Chinese population compared to open aneurysm repair (OAR), 36 patients with RAAA undergoing either OAR or eEVAR in National Taiwan University Hospital from 2005 to 2012 were analyzed retrospectively. Thirty-five (97.2 %) patients were treated. Among them, 20 (57.1 %) were treated by OAR and 15 (42.9 %) by eEVAR. The overall 30-day survival rate was 77.1 %. There was no significant difference in 30-day mortality rate (OAR 15.0 % vs. eEVAR 33.3 %, p = 0.201) and midterm mortality rate (OAR 20.0 % vs. eEVAR 46.7 %, p = 0.093) between these two groups. On univariate analysis, free peritoneal rupture (p < 0.001), pre-operative shock (p = 0.001) and female gender (p = 0.016) are related to a higher 30-day mortality rate, while free peritoneal rupture (p = 0.012) and pre-operative shock (p = 0.030) are associated with a higher midterm mortality rate in both repair techniques. On multivariate analysis, free peritoneal rupture was associated with higher 30-day (OR 26.0, 95 % CI 2.2-295.6, p = 0.009) and midterm (OR 13.1, 95 % CI 1.2-37.6, p = 0.032) mortality rates. In patients with RAAA, there is no significant difference in 30-day mortality and midterm mortality between eEVAR and OAR groups in our study. eEVAR could be an alternative therapy for anatomically suitable RAAA in a Chinese population.

The sharp end of cardiovascular disease in New Zealand: A review of acute type A aortic dissections of the Waikato.

AIM: Acute type A aortic dissections are lethal cardiovascular surgical emergencies. This study is a retrospective comparative review of mortality in Type A aortic dissections between Maori and non-Maori populations of the Midland DHBs catchment area. METHOD: 143 patients identified with diagnosis of type A aortic dissections at Waikato Hospital from 1990 to 2013, as identified in Waikato Hospital clinical records and cardiothoracic surgery database. The Maori and non-Maori populations were compared according to demographics, 30-day survival and 5-year survival. RESULT: The overall 30-day mortality rate of 28% was consistent with published international data, but there were significant ethnic and gender disparities related to the high prevalence of cardiovascular risk factors, particularly in the Maori population. Maori have a significantly higher prevalence of type A aortic dissections (2.5 per 10,000) compared to non-Maori (1.4 per 10,000) and have a 5-year earlier mean age at presentation compared to non-Maori. Maori females have the highest mortality rates with almost half succumbing within 30 days of surgery (45.5%). CONCLUSION: The future promises an increasing incidence of acute type A aortic dissections in a younger Maori population with severe disease burden and less reserve, as well as in an elderly population where age is an independent predictor of worse operative mortality, morbidity and reduced long-term survival. GP and specialist collaborative directions are identified towards evolution of surgery and systems to maintain, if not improve, early and late survival rates in the Midland DHBs catchment region.

Ethnic inequalities in incidence, survival and mortality from abdominal aortic aneurysm in New Zealand.

BACKGROUND: Ethnic variation in abdominal aortic aneurysm (AAA) incidence, survival and mortality is not well documented and yet has important equity implications for screening programmes. This study quantifies ethnic differences in hospital incidence, mortality and survival from AAA among Maori, Pacific, Asian and European/other ethnicities in New Zealand (NZ). METHODS: Retrospective analysis of linked NZ hospital and death register records identified all patients admitted to a public hospital with a diagnosis of AAA and deaths from AAA from 1996 to 2007. Patients were grouped by ethnicity as Asian, Maori, Pacific or European/other. RESULTS: Compared with the European/other group, Maori were 8.3 years younger at first admission, had higher mortality rates (RR=1.30, 95% CI 1.06 to 1.60 for men; RR=2.66, CI 2.13 to 3.31 for women), lower 1-year cumulative relative survival (60% vs 73% for men and 56% vs 67% for women; p<0.0001 for both) and were much less likely to have their aneurysm repaired electively (39.6% vs 61.1%; p<0.00001). Also, Maori women but not men were found to have a significantly higher standardised incidence rate (RR=1.56, 95% CI 1.37 to 1.79). In contrast, the incidence rate ratio for Asians (both men and women) was just 0.38 (95% CI 0.27 to 0.54 and 0.30 to 0.47, respectively) and both sexes also had a significantly lower mortality rate than European/other. Pacific men but not women also had a significantly lower incidence rate and frequency of aneurysm repair (40.0%; p=0.027). CONCLUSIONS: Ethnic variation in the incidence, mortality and cumulative relative survival from AAA in NZ resembles ethnic inequalities in other health outcomes. This provides additional support for screening on equity grounds.

Pattern of aortic aneurysms in an African country.

OBJECTIVE: We sought to describe the regional, age, and sex distribution; diagnosis; treatment; and outcome of aortic aneurysms in a Kenyan population. METHODS: This was a retrospective study at Kenyatta National Hospital, Kenya. Records of black African patients whose final diagnosis was aortic aneurysm over the period from January 1998 to December 2007 were examined. Frequencies and means are presented in tables and bar charts. RESULTS: Two hundred sixty-four (92 male and 172 female patients) files were analyzed. The mean age was 56.15 years. Two hundred twenty-three (84.5%) aneurysms occurred in the abdominal aorta, followed by the descending aorta (7.5%), ascending aorta, (3.8%) and arch (1.9%). In 2.3% of cases, both the abdominal and thoracic aortas were affected. The male/female ratio was 1:1.9. Pain with swelling or a pulsatile mass was the predominant feature. More than 50% of the cases were diagnosed by means of ultrasonographic analysis. Sixty-one (23.1%) aneurysms were ruptured, and of this group, 44 (72.1%) patients died. Successful open surgical repair was done in 157 (59.5%) patients. Hypertension was a comorbidity in 137 (51.9%) cases. CONCLUSIONS: Aortic aneurysms in Kenya show abdominal segment and female predominance, occur 10 to 15 years earlier than in white populations, and carry high mortality from rupture. Hypertension was the leading associated risk factor. Ultrasonographic screening and control of blood pressure might be useful preventive measures.

The impact of race and insurance type on the outcome of endovascular abdominal aortic aneurysm (AAA) repair.

BACKGROUND: Although mortality and complication rates for abdominal aortic aneurysm (AAA) have declined over the last 20 years, operative complication rates and perioperative mortality are still high, specifically for repair of ruptures. The goal of this study was to determine the influence of insurance type and ethnicity while controlling for the influences of potential confounders on procedure selection and outcome following endovascular AAA repair (EVAR). METHODS: Using the Nationwide Inpatient Sample (NIS) database, we identified patients who underwent EVAR repair of ruptured and elective infrarenal AAA, between 1990 and 2003. Insurance type and ethnicity were analyzed against the primary outcome variables of mortality and major complications. The potential confounders of age, gender, operative location, diabetes, and Deyo index of comorbidities, were controlled. RESULTS: Bivariate analyses demonstrated significant differences between insurance types and ethnicity and mortality and complications. Patients who were self pay had adverse outcomes in comparison to Private insurance. Whites encountered less perioperative mortality and postoperative complications than Blacks and Hispanics. CONCLUSIONS: After controlling for previously identified associative factors for AAA outcome, ethnicity and insurance type does influence EVAR surgical outcome. Subsequent studies that break down emergent repair vs elective surgery and that longitudinally stratify delay in surgery, or time to admission may be useful.

A decade of change in abdominal aortic aneurysm repair in the United States: Have we improved outcomes equally between men and women?

OBJECTIVES: Abdominal aortic aneurysm (AAA) repair has undergone vast changes in the last decade. We reviewed a national database to evaluate the effect on utilization of services and rupture rates. METHODS: From the Centers for Medicare Services (CMS), a 5% inpatient sample was obtained for 1994 to 2003 as beneficiary encrypted files (5% BEF) and as a limited data set file after 2001. Files were translated into Microsoft Access by using a custom program. Queries were performed using International Classification of Diseases (9th Revision) (ICD-9) diagnosis codes 441.3 (ruptured AAA) or 441.4 (non-ruptured AAA) and ICD-9 procedure codes 38.34, 38.36, 38.44, 38.64, 39.25, 39.52 for open, and 39.71 (available after October 2000) for endovascular repair. The 5% BEF totals were multiplied by 20 to calculate yearly volumes. Total cases were divided into the yearly CMS population of elderly Medicare recipients for repair rates per capita and are reported as cases per 100,000 elderly Medicare recipients. Statistics were performed using chi2, Student's t test, nonparametric tests, and multiple regression analysis; P < or = .05 was considered significant. RESULTS: Elective AAA repairs declined from 94.4/100,000 in 1994 to 87.7/100,000 in 2003. AAA rupture surgery declined from 18.7/100,000 (1994) to 13.6/100,000 (2003). Rupture repairs from 1994 to 2003 decreased by 29% for men and by 12% for women (P < .001). Rupture mortality has not changed, but the average is significantly higher for women at 52.8%, with men averaging 44.2% (P < .001). Mortality for elective AAA repair has decreased from 5.57% (1994) to 3.20% (2003) in men (P < .001) and from 7.48% (1994) to 5.45% (2003) in women (P < .001). Multivariate analysis demonstrated increasing age, female sex, and open surgery (vs endovascular) were significant predictors of elective and ruptured AAA repair mortality. For 2003 elective AAA repairs, the average length of stay was 6.9 days in men and 8.9 days in women (P < .01) For 2003, men were more likely to be discharged to home after rupture (32.9% of men vs 23.3% of women; P < .001) and elective repair (84.5% of men vs 70.1% of women; P < .001). CONCLUSIONS: Improvements in AAA management in the last decade have decreased aneurysm-related deaths and reduced the incidence of aneurysm ruptures, with a lower utilization of services. Women, however, continue to have a consistently higher mortality for open and ruptured AAA repair and are less likely to return to home after either.