Broad responses and attitudes to having music in surgery (the BRAHMS study) - a South African perspective.

BACKGROUND: Music is played in operating theatres (OTs) throughout the world, though controversy around its use exists. While some clinicians may find background music favourable to the theatre mood and a way to augment surgical performance, there is concern raised over its distracting and noise-creating properties. METHODS: In this prospective observational study, between August and December 2021, 110 surgeons and registrars in South Africa responded to a survey investigating the way they use music, and their perceptions and attitudes towards its effect on the OT environment. RESULTS: In this cohort, 66% were male, 29% were consultants and the most common age range was 30-39 years old. Eighty per cent of respondents reported that music was played at least "sometimes", with 74% reporting that they enjoyed it. Easy Listening was the most played and preferred genre followed by Top 40/Billboard hits. Overwhelmingly, respondents reported that background music in the OT improved temperament, focus, mood, and performance, though over a quarter felt it worsened communication. Thirty-one per cent of respondents reported that the choice of music depended on the type of operation, and 70% would turn music down or off during crises. Those who enjoyed music in their spare time were significantly more likely to enjoy music in the OT and perceive it positively. CONCLUSION: This study provides a window into the surgeons' use of and attitudes to intraoperative music in South Africa. While overall, music is viewed positively by this cohort, some concerns remain regarding communication and distractedness. Further interventional and qualitative studies would be useful.

Patients' expectation of postoperative course and satisfaction following cardiac surgery.

INTRODUCTION: In patients undergoing cardiac surgery, preoperative concerns, expectations of the impact of surgery, anticipated recovery timelines, and pre- and postoperative education, which impact recovery and quality-of-life, are not well documented. These factors are important with the increase in virtual consultations, the availability of internet-based information and increased use of minimally invasive surgical procedures. METHODS: Patients who underwent cardiac surgery between January 2016 and December 2019 took part in an online survey examining preoperative concerns, information provision, use of digital channels, satisfaction with surgery, impact on health and resumption of daily activity. 80 patients completed the survey. RESULTS: There was a high rate of overall post-surgical satisfaction (86%); 71% of respondents reported an improvement in physical health, 45% in mental health and 70% in their quality-of-life. The usefulness of information provided by the National Health Service varies across different stages of the patient experience. Although approximately 90% of respondents found the information provided at each stage at least 'somewhat' helpful, the proportion who found the information 'very' helpful was lower (68% for pre-procedure; 55% for post-discharge). The majority (79%) said that they felt prepared for their operation. Survey responses highlighted areas of lower understanding, including survival rate, levels of postoperative pain, duration of hospital stay and when the patient could return to normal physical activity. CONCLUSIONS: Levels of satisfaction with the outcomes of heart surgery are high, and the majority of patients report positive health outcomes. However, there is room for improvement in patients' understanding of survival rate and level of pain post-procedure. There is also a clear desire among patients for a more surgical team-based face-to-face consultation.

Big data in vascular surgery: registries, international collaboration and future directions.

Given the increasing availability of large data set, small single-institutional series raise decreasing attention. Rapid expansion of technology from electronic medical records to easily accessible internet access, and widespread use and acceptance of registries in the medical world has allowed for research and quality improvement efforts using 'big data'. Big data, although technically not defined, typically refers to large databases that can be used to investigate common or rare disease processes or outcomes, describe variation in clinical practices across and between different specialties at various practice location, whilst allowing important information about trends over time. Big data have allowed investigators to quickly assimilate cohorts of patients and/or procedures to answer current questions, with more complete population representation and improved generalizability whilst decreasing the likelihood of power problems and type II errors. On the other hand, pitfalls still exist with the growing problem of hypothesis fishing, lack of granularity and the fear by many clinicians that registry transparency may have already gone too far, where surgery groups or individual surgeon outcomes are readily available to patients and referring providers. Within vascular surgery specifically, big data have expanded over the last decade and now includes regional, national and global registries that have major benefits of gathering specific clinical and procedural information within vascular surgery. In this review, we highlight the main vascular surgery registries and recap a few success stories of how the registries have been leveraged to benefit discovery, quality improvement and ultimately patient care. Additionally, we outline future directions that will be imperative for continued expansion, acceptance and adoption of 'big data' utilization inpatients with vascular disease.

Paradigm shifts in abdominal aortic aneurysm management based on vascular registries.

Abdominal aortic aneurysm (AAA) is a relatively common and potentially fatal disease. The management of AAA has undergone extensive changes in the last two decades. High quality vascular surgical registries were established early and have been found to be instrumental in the evaluation and monitoring of these changes, most notably the wide implementation of minimally invasive endovascular surgical technology. Trends over the years showed the increased use of endovascular aneurysm repair (EVAR) over open repair, the decreasing perioperative adverse outcomes and the early survival advantage of EVAR. Also, data from the early EVAR years changed the views on endoleak management and showed the importance of tracking the implementation of new techniques. Registry data complemented the randomized trials performed in aortic surgery by showing the high rate of laparotomy-related reinterventions after open repair. Also, they are an essential tool for the understanding of outcomes in a broad patient population, evaluating the generalizability of findings from randomized trials and analysing changes over time. By using large-scale data over longer periods of time, the importance of centralization of care to high-volume centres was shown, particularly for open repair. Additionally, large-scale databases can offer an opportunity to assess practice and outcomes in patient subgroups (e.g. treatment of AAA in women and the elderly) as well as in rare aortic pathologies. In this review article, we point out the most important paradigm shifts in AAA management based on vascular registry data.

Top 10 candidate aortic disease trials.

Aortic pathologies such as aneurysm, dissection and trauma are relatively common and potentially fatal diseases. Over the past two decades, we have experienced unprecedented technical and medical developments in the field. Despite this, there is a great need, and great opportunities, to further explore the area. In this review, we have identified important areas that need to be further studied and selected priority aortic disease trials. There is a pressing need to update the AAA natural history and the role for endovascular AAA repair as well as to define biomarkers and genetic risk factors as well as influence of gender for development and progression of aortic disease. A key limitation of contemporary treatment strategies of AAA is the lack of therapy directed at small AAA, to prevent AAA expansion and need for surgical repair, as well as to reduce the risk for aortic rupture. Currently, the most promising potential drug candidate to slow AAA growth is metformin, and RCTs to verify or reject this hypothesis are warranted. In addition, the role of endovascular treatment for ascending pathologies and for uncomplicated type B aortic dissection needs to be clarified.

Lack of an effective drug therapy for abdominal aortic aneurysm.

Abdominal aortic aneurysm (AAA) rupture is a common cause of death in adults. Current AAA treatment is by open surgical or endovascular aneurysm repair. Rodent model and human epidemiology, and genetic and observational studies over the last few decades have highlighted the potential of a number of drug therapies, including medications that lower blood pressure, correct dyslipidaemia, or inhibit thrombosis, inflammation or matrix remodelling, as approaches to managing small AAA. This review summarizes prior AAA pathogenesis data from animal and human studies aimed at identifying targets for the development of drug therapies. The review also systematically assesses past randomized placebo-controlled drug trials in patients with small AAAs. Eleven previously published randomized-controlled clinical trials testing different drug therapies aimed at slowing AAA progression were identified. Five of the trials tested antibiotics and three trials assessed medications that lower blood pressure. Meta-analyses of these trials suggested that neither of these approaches limit AAA growth. Allocation to blood pressure-lowering medication was associated with a small reduction in AAA rupture or repair, compared to placebo (relative risk 0.94, 95% confidence intervals 0.89, 1.00, P = 0.047). Three further trials assessed the effect of a mast cell inhibitor, fibrate or platelet aggregation inhibition and reported no effect on AAA growth or clinical events. Past trials were noted to have a number of design issues, particularly small sample sizes and limited follow-up. Much larger trials are needed to properly test potential therapeutic approaches if a convincingly effective medical therapy for AAA is to be identified.

Attenuation of adverse effects of noise induced hearing loss on adult neurogenesis and memory in rats by intervention with Adenosine A2A receptor agonist.

Hearing loss and cognitive decline are commonly associated with aging and morbidity. Present clinical interest lies in whether peripheral hearing loss promotes cognitive decline and if prophylaxis with selective adenosine receptor agonist CGS21680 effectively mitigates the adverse effects. In the current study, male Sprague Dawley rats weighing 200-250 g m were randomly allocated into three groups: Group 1) rats exposed to 100 dB SPL white noise, 2 h a day for 15 consecutive days, 2) rats supplemented with an adenosine receptor agonist, CGS21680 at 100 µg/kg/day prior to noise exposure and 3) unexposed control rats. Baseline hearing and cognition assessed by auditory brainstem response (ABR) and water maze respectively was undertaken for all the groups. Phalloidin stain and synaptic ribbons count in cochlea, and, Ki67, DCX and NeuN in hippocampus were observed by immunohistochemistry. It was inferred that noise exposed rats showed elevated thresholds of ABR and poorer performances in spatial working memory when compared with controls. On the contrary, CGS21680 administered group exhibited improved ABR and cognitive functions with shorter mean latency and path-length to reach the platform, significant reduction in the noise induced loss of synaptic ribbons count and increased number of Ki67 and doublecortin (DCX) positive cells compared to their noise exposed counterparts. Pharmacologic intervention with selective A2A receptor agonist CGS21680 provided adequate protection from noise by effectively maintaining hearing threshold levels, cell viability in cochlea and hippocampus & functional/intact reference memory.

Treatment of aortic aneurysms registered in Swedvasc: Development reflected in a national vascular registry with an almost 100% coverage.

Swedvasc is a registry for vascular surgical procedures, both open and endovascular. It was started in 1987 and since 1994 the whole population of Sweden is covered, at present around 10 million inhabitants. In a recent external validation, it was found to be highly accurate with abdominal aortic aneurysm surgery correctly reported in >96%. In this paper various factors explaining the almost 100% coverage are discussed, one important being that the registry has been developed and maintained within the profession of vascular surgery and not dictated by authorities. Another factor of importance is the possibility to use data in various research projects and so far 15 PhD theses have used Swedvasc data. To exemplify the practical use of the registry, the treatment of abdominal aortic aneurysms is scrutinized and among the various complications abdominal compartment syndrome is analyzed. Several significant temporal changes have been observed over the almost 25 years of Swedvasc: increasing use of endovascular surgery, treatment of aneurysms detected by screening , decreasing treatment for rupture, improved outcome, increasing treatment of older patients and patients with comorbid conditions. In conclusion, a high quality national vascular registry can be valid with high compliance and can be used to study population-based development of treatment and outcome. It can also be used to perform international comparisons with other registries, thereby getting an indication of the quality of care.

Acromio-Clavicular Joint Dislocation Types IV to VI: Does the Outcome with the modified Weaver-Dunn Procedure Justify the Treatment?

Introduction: The optimal surgical treatment for acromioclavicular joint (ACJ) injuries remains controversial. The modified Weaver-Dunn (WD) procedure is one of the frequently used techniques. Recently when it was compared with anatomical autogenous tendon graft reconstruction procedures, the results were inferior. However, these anatomical procedures are technically more demanding with small margin of error and they have tendency for postoperative pain because of extra donor site incision. Materials and Methods: Forty patients with type IV to VI ACJ dislocations were treated by modified WD procedure using non-absorbable synthetic suture passed through the base of coracoid process for augmentation of transferred coraco-acromial (CA) ligament. Functional outcome was assessed using the Oxford Shoulder Score, Nottingham Clavicular Score and Visual Analog Score (VAS) at the final follow-up after surgery. Results: The mean pre-operative Oxford Shoulder Score improved from 25.22±2.64 (range 20 to 30) to 44.75±1.99 (range 40 to 48) and mean pre-operative Nottingham Shoulder Score improved from 49.25±4.91 (range 39 to 58) to 87.27±4.39 (range 79 to 96) at last follow-up after surgery with p-value <0.001. Thirty-five (87.5%) patients had excellent outcomes, four (10%) patients had good outcomes and one (2.5%) patient had fair outcome. Thirty-eight (95%) patients had no pain while two (5%) had moderate pain based on VAS score. Conclusion: Modified Weaver-Dunn is a simple well established technique for grade IV to VI ACJ dislocation. We cannot consider this procedure as old and outdated on the argument that the long term functional outcomes are not suboptimal.

Is simultaneous bilateral total knee arthroplasty safe in geriatric population? A retrospective cohort study with upto 9 years follow up.

INTRODUCTION: Considering the old age, uncertain life expectancy, co-morbidities and fear of postoperative complications, elderly patients often hesitate to undergo simultaneous bilateral total knee arthroplasty (SBTKA). MATERIALS & METHODS: A retrospective study of SBTKA in 46 patients (92 knees) of age >70 years done between 2003 and 2012. Mean age was 80.13 ± 5.24 years (range -70-93 years). RESULTS: 74 percent had 1 or more major medical problems. There was a significant improvement of KSS at six months (p value = 0.00). CONCLUSION: With expected benefits of surgery, SBTKA seems a safe, efficient, and viable procedure for carefully selected elderly patients.

Precontoured Clavicular Locking Plate with Broad Lateral End: A Newly Designed Plate for Lateral Third Clavicle Fractures.

Introduction: Various treatment modalities are available but no consensus has been reached for optimal treatment of lateral third clavicle fractures. Precontoured locking plates with broad lateral end for multiple screws fixation is a newly designed plate for lateral third clavicle fractures. The objective of our study was to analyse the functional outcomes as well as complications of this technique in a significant number of cases with long follow-up duration. Materials and Methods: Forty-six patients with distal third clavicle fractures were treated by precontoured clavicular locking plate with broad lateral end. Functional outcomes were assessed on the basis of Constant-Murley Shoulder Outcome Score and University of California, Los Angeles (UCLA) Shoulder Rating Score, active shoulder range of motion, time for fracture union and coraco-clavicular distance. Results: The mean Constant-Murley score was 92.56±4.47 (range: 79-98) for injured side and 96.22±2.23 (range: 90-100) for normal side with p-Value 0.56. Mean coraco-clavicular distance at final follow-up was 10.52±1.13 mm (range 9.7 to 11.7 mm) in injured side and 10.25±0.98 mm (range 9.6 to 11.2 mm) in normal side. Mean UCLA Shoulder Rating Score was 32.55±2.12 (range: 27-34) for injured side and 33.46±1.88 (range: 31- 35) on normal side with p value 0.58. No major complications that necessitated revision of surgery occurred in our study. Conclusion: This newly designed plate seemed extremely useful in successful union of lateral third clavicle fractures, with reduced rate of complications like fixation failures, iatrogenic rotator cuff injury, AC joint osteoarthritis and sub-acromial bursitis, with good functional outcomes.

Follow-up after endovascular aortic aneurysm repair can be stratified based on first postoperative imaging.

BACKGROUND: Lifelong postoperative surveillance is recommended following endovascular aneurysm repair (EVAR). Although the purpose is to prevent and/or identify complications early, it also results in increased cost and workload. This study was designed to examine whether it may be possible to identify patients at low risk of complications based on their first postoperative CT angiogram (CTA). METHODS: All patients undergoing EVAR in two Swedish centres between 2001 and 2012 were identified retrospectively and categorized based on the first postoperative CTA as at low risk (proximal and distal sealing zone at least 10 mm and no endoleak) or high risk (sealing zone less than 10 mm and/or presence of any endoleak) of complications. RESULTS: Some 326 patients (273 men) with a CTA performed less than 1 year after EVAR were included (low risk 212, 65·0 per cent; high risk 114, 35·0 per cent). There was no difference between the groups in terms of sex, age, co-morbidities, abdominal aortic aneurysm (AAA) diameter, preoperative AAA neck anatomy, stent-graft type or duration of follow-up (mean(s.d.) 4·8(3·2) years). Five-year freedom from AAA-related adverse events was 97·1 and 47·7 per cent in the low- and high-risk groups respectively (P < 0·001). The corresponding freedom from AAA-related reintervention was 96·2 and 54·1 per cent (P < 0·001). The method had a sensitivity of 88·3 per cent, specificity of 77·0 per cent and negative predictive value of 96·6 per cent to detect AAA-related adverse events. The number of surveillance imaging per AAA-related adverse event was 168 versus 11 for the low-risk versus high-risk group. CONCLUSION: Two-thirds of patients undergoing EVAR have an adequate seal and no endoleak on the first postoperative CTA, and a very low risk of AAA-related events up to 5 years. Less vigilant follow-up after EVAR may be considered for these patients.

Comparative analysis of the outcomes of elective abdominal aortic aneurysm repair in England and Sweden.

BACKGROUND: There is substantial international variation in mortality after abdominal aortic aneurysm (AAA) repair; many non-operative factors influence risk-adjusted outcomes. This study compared 90-day and 5-year mortality for patients undergoing elective AAA repair in England and Sweden. METHODS: Patients were identified from English Hospital Episode Statistics and the Swedish Vascular Registry between 2003 and 2012. Ninety-day mortality and 5-year survival were compared after adjustment for age and sex. Separate within-country analyses were performed to examine the impact of co-morbidity, hospital teaching status and hospital annual caseload. RESULTS: The study included 36 249 patients who had AAA treatment in England, with a median age of 74 (i.q.r. 69-79) years, of whom 87·2 per cent were men. There were 7806 patients treated for AAA in Sweden, with a median of age 73 (68-78) years, of whom 82·9 per cent were men. Ninety-day mortality rates were poorer in England than in Sweden (5·0 versus 3·9 per cent respectively; P < 0·001), but were not significantly different after 2007. Five-year survival was poorer in England (70·5 versus 72·8 per cent; P < 0·001). Use of EVAR was initially lower in England, but surpassed that in Sweden after 2010. In both countries, poor outcome was associated with increased age. In England, institutions with higher operative annual volume had lower mortality rates. CONCLUSION: Mortality for elective AAA repair was initially poorer in England than Sweden, but improved over time alongside greater uptake of EVAR, and now there is no difference. Centres performing a greater proportion of EVAR procedures achieved better results in England.

Scaphoid nonunion: does open reduction, bone grafting and Herbert screw fixation justify the treatment?

PURPOSE: Conventional bone grafting and Herbert screw fixation give satisfactory results for scaphoid nonunion; however, vascularized bone grafting has superior results, especially in the case of avascular necrosis of proximal fragment. Vascularized bone grafting is technically more demanding with small error of margin, problems of getting the appropriate graft, fixation and incorporation, and requires longer duration for wrist immobilization. METHODS: Forty-five patients of scaphoid nonunion were treated by cancellous bone grafting, cortex containing graft if required and Herbert screw fixation. Functional outcomes were assessed at the latest follow up after surgery (minimum one year after surgery). RESULTS: The average pre-operative and post-operative scapho-lunate angle, grip strength, flexion-extension movement, radio-ulnar movement, scaphoid index and modified mayo score were improved from 49.60 ± 6.40° (37-66) to 36.26 ± 4.73° (range 28-46), 20.66 ± 3.17 kg (15-27) to 31.11 ± 3.29 kg (range 25-40), 78.57 ± 14.22° (45-110) to 132.86 ± 13.90° (100-165), 30.06 ± 6.06° (20-44) to 44.95 ± 6.37°(range 35-59), 0.66 ± 0.076 (0.55-0.79) to 0.60 ± 0.065 (range 0.49-0.73) and 58.66 ± 5.24 (50-70) to 84.37 ± 5.01 (range 75-95), respectively, with P value <0.001. Based on modified mayo score, 21 (46.7%) patients had excellent results, 19 (42.2%) had good results, 4 (8.9%) had fair results and one patient (2.2%) had poor results. CONCLUSION: Bone grafting and Herbert screw fixation provides a good option for treatment of scaphoid nonunion, especially in the absence of avascular necrosis of proximal fragment. More importantly, vascularized bone grafting in all scaphoid nonunion may not be necessary and could otherwise have been united uneventfully by this technique. However, avascular necrosis of proximal fragment must be ruled out pre-operatively as well as intra-operatively.

Editor's Choice - Prolonged ICU Length of Stay after AAA Repair: Analysis of Time Trends and Long-term Outcome.

OBJECTIVE: The aim of the study was to investigate the frequency and outcome of prolonged intensive care unit (ICU) length of stay (LOS) after abdominal aortic aneurysm (AAA) repair in the endovascular era. METHODS: All patients operated on for AAA between 1999 and 2013 at Uppsala University hospital were identified. Data were retrieved from the Swedish Vascular registry, the Swedish Intensive Care registry, the National Population registry, and case records. Prolonged ICU LOS was defined as ≥ 48 h during the primary hospital stay. Patients surviving ≥ 48 h after AAA surgery were included in the analysis. RESULTS: A total of 725 patients were identified, of whom 707 (97.5%) survived ≥ 48 h; 563 (79.6%) underwent intact AAA repair and 144 (20.4%) ruptured AAA repair. A total of 548 patients (77.5%) required < 48 h of intensive care, 115 (16.3%) 2-6 days and 44 (6.2%) ≥ 7 days. The rate of prolonged ICU LOS declined considerably over time, from 41.4% of all AAA repairs in 1999 to 7.3% in 2013 (p < .001) whereas the use of endovascular aortic repair (EVAR) increased from 6.9% in 1999 to 78.0% in 2013 (p < .001). The 30 day survival rate was 98.2% for those with < 48 h ICU stay versus 93.0% for 2-6 days versus 81.8% for ≥ 7 days (p < .001); the corresponding 90 day survival was 97.1% versus 86.1% versus 63.6% (p < .001) respectively. For patients surviving 90 days after repair, there was no difference in long-term survival between the groups. CONCLUSION: During the period of progressively increasing use of EVAR, a simultaneous significant reduction in frequency of prolonged ICU LOS occurred. Although prolonged ICU LOS was associated with a high short-term mortality, long-term outcome among those surviving the initial 90 days was less affected.

A modified minimally invasive technique for intra-articular displaced calcaneal fractures fixed by transverse and axial screws.

The management of displaced, intra-articular calcaneal fracture represents a surgical challenge to even an experienced orthopedic surgeon. Plate osteosynthesis using an extended lateral approach is complicated by soft tissue problems, while those treated by closed reduction and percutaneous pinning cannot address all the intra-articular fragments sufficiently. The objective of our study is to evaluate restoration of subtalar joint and long-term functional outcomes in intra-articular displaced calcaneal fractures treated with transverse subcondral screws through a small incision on lateral aspect of calcaneus and percutaneously placed axial screws through the calcaneal tuberosity. Forty-five intra-articular calcaneal fractures were managed with this minimally invasive technique. Calcaneal height, width, length, Bohler's angle, and Gissane angle were measured preoperatively and last follow-up visit. Functional outcomes were assessed on the basis of American Orthopedic Foot and Ankle Society (AOFAS) ankle/hind foot score. Preoperative calcaneal length, height, width, Bohler's angle, and Gissane angle were improved from 68.62 ± 2.64 to 72.44 ± 2.63 mm, 39.28 ± 2.72 to 32.37 ± 2.65 mm, 47.04 ± 2.56 to 49.55 ± 2.45 mm, 12.66° ± 2.86° to 26.93° ± 2.57°, 123.91° ± 3.13° to 96.06° ± 3.92°, respectively, after surgery with P value <0.001. There were 21 (46.7%) excellent, 17 (37.8%) good, 4 (8.8%) fair, and 3 (6.7%) poor outcomes based on AOFAS ankle/hindfoot scores. Time to unite the fracture was 11.06 ± 1.82 weeks (range 8-16 weeks), and all fractures were united without major complications. Minimally invasive technique through a small incision on lateral aspect of calcaneus gives a moderately good exposure for anatomical restoration of Sander's type II and III calcaneal fractures fixed with both transverse and axial screws under fluoroscopic guidance.

Editor's Choice - Assessment of International Outcomes of Intact Abdominal Aortic Aneurysm Repair over 9 Years.

BACKGROUND: Case mix and outcomes of complex surgical procedures vary over time and between regions. This study analyses peri-operative mortality after intact abdominal aortic aneurysm (AAA) repair in 11 countries over 9 years. METHODS: Data on primary AAA repair from vascular surgery registries in 11 countries for the years 2005-2009 and 2010-2013 were analysed. Multivariate adjusted logistic regression analyses were carried out to adjust for variations in case mix. RESULTS: A total of 83,253 patients were included. Over the two periods, the proportion of patients ≥80 years old increased (18.5% vs. 23.1%; p < .0001) as did the proportion of endovascular repair (EVAR) (44.3% vs. 60.6; p < .0001). In the latter period, 25.8% of AAAs were less than 5.5 cm. The mean annual volume of open repairs per centre decreased from 12.9 to 10.6 between the two periods (p < .0001), and it increased for EVAR from 10.0 to 17.1 (p < .0001). Overall, peri-operative mortality fell from 3.0% to 2.4% (p < .0001). Mortality for EVAR decreased from 1.5% to 1.1% (p < .0001), but the outcome worsened for open repair from 3.9% to 4.4% (p = .008). The peri-operative risk was greater for octogenarians (overall, 3.6% vs. 2.1%, p < .0001; open, 9.5% vs. 3.6%, p < .0001; EVAR, 1.8% vs. 0.7%, p < .0001), and women (overall, 3.8% vs. 2.2%, p < .0001; open, 6.0% vs. 4.0%, p < .0001; EVAR, 1.9% vs. 0.9%, p < .0001). Peri-operative mortality after repair of AAAs <5.5 cm was 4.4% with open repair and 1.0% with EVAR, p < .0001. CONCLUSIONS: In this large international cohort, total peri-operative mortality continues to fall for the treatment of intact AAAs. The number of EVAR procedures now exceeds open procedures. Mortality after EVAR has decreased, but mortality for open operations has increased. The peri-operative mortality for small AAA treatment, particularly open surgical repair, is still considerable and should be weighed against the risk of rupture.