Aneurysm rupture is independently associated with increased late mortality in those surviving abdominal aortic aneurysm repair.

PURPOSE: The aim of this study was to define whether veterans who survived repair of ruptured abdominal aortic aneurysms (AAA) experienced late survival rates similar to those surviving repair of intact AAA. METHODS: All veterans undergoing AAA repair in DRGs 110 and 111 during fiscal years 1991-1995 were identified using the Veterans Affairs (VA) Patient Treatment File (PTF). Late mortality was defined using VA administrative databases including the Beneficiary Identification and Record Locator System and PTF. Illness severity and patient complexity were defined using PTF discharge data that were further analyzed by Patient Management Category software. Veterans were followed up to 6 years after AAA repair. RESULTS: During the study, 5833 veterans underwent repair of intact AAA while 427 had repair of ruptured AAA in all VA medical centers. Operative mortality was defined as that which occurred within 30 days of surgery or during the same hospitalization as aneurysm repair. For those undergoing repair of intact AAA, operative mortality thus defined was 4.5% (265/5833). Operative mortality was 46% (195/427) after repair of ruptured AAA. Overall mortality (including operative mortality) during 2.62+/-1.61 years follow-up was 22% (1282/5833) with intact AAA versus 61% (260/427) for those with ruptured AAA (P<0.001). Further analysis of survival outcomes was performed in patients who survived AAA repair (i.e., those who were discharged alive and lived 30 days or more after surgery). Of those who initially survived repair of ruptured AAA, 28% (65/232) died during follow-up versus 18% (1017/5568) who initially survived repair of intact AAA (odds ratio 1.74; 95% confidence limits 1.30-2.34; P<0.001). In those initially surviving AAA repair, stepwise logistic regression analysis revealed that increasing age, illness severity, patient complexity, as well as AAA rupture and aortic graft complications were increasingly and independently associated with late mortality. Mean survival time was 1681 days for those who survived >30 days and who were discharged alive after repair of ruptured AAA versus 1821 days for those who initially survived repair of intact AAA (P< 0.001). CONCLUSIONS: In addition to higher postoperative mortality rates with ruptured AAA, mortality during follow-up for survivors of AAA repair was also greater for those who survived repair of ruptured AAA. The toll taken by ruptured abdominal aortic aneurysms did not end in the immediate postoperative period.

Is there differential access to carotid endarterectomy based on gender?

The purpose of this study was to determine whether there was differential access to carotid endarterectomy (CEA) based on gender at our institution. In 1995, the year after ACAS results were published, 1774 carotid duplex studies were performed in our vascular laboratory in 765 men and 1009 women. The incidence of 50-99% carotid stenosis was 13% (n = 235) overall and did not differ between men (13.3%; 102/765) and women (13.2%; 133/1009). The frequency that patients subsequently underwent CEA was determined to assess whether men with significant carotid stenosis were more likely to undergo CEA than women. Attempts were made to contact patients with 50-99% stenosis directly. Data were available for 101 patients (41 men, 60 women) with 50-99% carotid stenosis diagnosed by carotid duplex. There was conflicting information regarding the possibility of gender bias in the selection of candidates for CEA: logistic regression analysis suggested that disease severity dictated surgical intervention, however, a significantly lower percentage of women with ICA/CCA peak systolic ratios > or =2.9 underwent CEA. This study cannot refute the possibility that gender bias existed in the selection of patients for CEA.

Massive hematuria in adults with Klippel-Trenaunay syndrome associated with vascular malformation of the bladder.

Although hematuria has been reported in children with Klippel-Trenaunay syndrome, it is a rare presentation in the adult population. Two cases of massive hematuria in adults with Klippel-Trenaunay syndrome are reported here. A unique feature was venous malformations of the bladder which were responsible for massive recurrent bleeding in 1 patient. The clinical presentation and management are discussed. Conservative endoscopic and arteriographic control seems to be appropriate as initial management in these patients.

Do patients with acute deep vein thrombosis have fever?

The purpose of this study was to determine whether those with lower extremity acute venous thrombosis have fever. During a recent 14.5-month period, 1847 patients undergoing lower extremity venous duplex scanning also had their oral temperature measured using a digital thermometer at the time of duplex examination. Patients were 57.8 +/- 17.3 years of age (range, 14 to 99). Temperature was 98.5 +/- 1.1 degrees F. Twenty-three patients had acute inferior vena cava thrombosis, 60 had acute iliac vein thrombosis, 138 had acute femoral venous thrombosis, and 131 had acute popliteal venous thrombosis. Calf vein thromboses were present in 102 patients, and 43 patients had superficial venous thrombosis. A total of 228 patients had acute lower extremity venous thrombosis in one or more of these venous segments. Temperature with acute lower extremity venous thrombosis was 98.7 +/- 1.05 degrees F versus 98.5 +/- 1.10 degrees F in those with no acute thrombosis. Although small, this temperature difference was statistically significant (P < 0.02). Acute deep venous thrombosis (DVT) was defined as acute popliteal or more proximal femoral, iliac, or vena cava thrombosis. The temperature for the 175 patients with acute DVT was 98.7 +/- 1.10 degrees F versus 98.5 +/- 1.10 degrees F for those without DVT (P < or = 0.035). There was no temperature that served to accurately differentiate those who did from those who did not have DVT. The frequency that patients with DVT had fever, defined as a temperature > or = 100 degrees F, was 9.1 per cent (16 of 175) with DVT versus 7.5 per cent (126 of 1678) without DVT (not significant). In the subgroup with a temperature > or = 101 degrees F, 4.6 per cent (8 of 175) with DVT had such a fever versus 3.4 per cent (57 of 1672) without DVT (not significant). Those undergoing venous duplex who were found to have acute lower extremity venous thrombosis, including acute DVT, had statistically higher temperatures, but such temperature differences were minimal. The incidence of fever, defined as a temperature > or = 100 degrees F or > or = 101 degrees F, was not different between those with and those without acute DVT. It appears that the presence of fever may not be a sensitive or specific indicator for the presence of underlying acute DVT.

Major lower extremity amputation in Veterans Affairs medical centers.

Our objective was to assess outcomes for 8696 patients who underwent 9236 above- (AKA) and/or below-knee (BKA) amputations during a 4-year period for disorders of the circulatory system. Veterans Affairs (VA) Patient Treatment File (PTF) data were acquired for all patients in Diagnosis Related Groups (DRGs) 113 and 114 hospitalized in VA medical centers (VAMCs) during fiscal years 1991-1994. Data were further analyzed by Patient Management Category (PMC) software, which measured illness severity, patient complexity, and relative intensity score (RIS), a measure of resource utilization. The results of this analysis showed that mortality and morbidity rates remain high after AKA and BKA. Differing amputation practice patterns found in this study warrant further investigation.

Outcomes after lower-extremity reconstruction in DRGs 478 and 479.

PURPOSE: To assess outcomes for 21,261 patients in DRGs 478 and 479 hospitalized in Veterans Affairs Medical Centers (VAMCs) during fiscal years 1991-1994. DRGs 478 and 479 contain patients undergoing a variety of vascular procedures including lower-extremity arterial reconstruction. METHODS: VA Patient Treatment File (PTF) data were analyzed using Patient Management Category (PMC) software which defined illness severity, patient complexity as defined by PMC count, and calculated resource intensity scale (RIS), a measure of resource utilization, for each admission. RESULTS: In-hospital mortality rate was 3.16% (671/21,261) for all patients. Mortality did not differ between the 14,155 patients who underwent extremity arterial reconstruction (3.22%) and the remaining patients (3.03%). The incidence of ICD-9-CM-coded complications was 20.4% after limb revascularization versus 12.8% for remaining patients (P < 0.001). Length of stay (LOS) was 18.6 +/- 17.6 days with versus 10.3 +/- 14. 5 days without limb revascularization (P < 0.001). As defined in this study, patients who underwent limb revascularization were older (64.1 +/- 9.6 vs 62.2 +/- 11.0, P < 0.001); had higher illness severity scores (3.63 +/- 1.60 vs 2.72 +/- 1.72, P < 0.001); were more complex (had higher PMC count: 2.59 +/- 1.35 vs 2.54 +/- 1.34, P = 0.016); and required utilization of more resources (had higher RIS: 2.16 +/- 0.81 vs 1.68 +/- 0.76, P < 0.001) than remaining patients. Logistic regression analysis limited to those undergoing extremity revascularization revealed that age, presence of complications, patient complexity, illness severity, and acute arterial thromboembolism were increasingly and independently associated with greater in-hospital mortality. The logistic regression model also showed that the type of arterial reconstruction was related to in-hospital mortality: arterial bypass (ICD-9-CM 39.29) was associated with lower mortality. Outcomes were defined for the subgroup (n = 7,728) undergoing arterial bypass (ICD-9-CM 39.29) who were assigned to Patient Management Category 4101, 4113, or 4141: Mortality rates were 2.26, 2.19, and 5.03% for those undergoing elective bypass (n = 3003), urgent bypass (n = 3,513), and bypass for gangrene (n = 1212), respectively. Octogenarians did not experience higher mortality rates after elective bypass ¿1.4% (1/73) vs 2.3% (67/2,930), n.s., but experienced higher mortality rates after urgent bypass ¿8.6% (8/93) vs 2.0% (69/3,420), P < 0.001 and after bypass for gangrene ¿11.6% (5/43) vs 4.8% (56/1,169), P < 0.045. CONCLUSIONS: Outcomes for patients in DRGs 478 and 479 who underwent extremity revascularization differed from those who did not. Outcomes varied by the type of arterial reconstruction and its urgency and indication and within selected subpopulations (i.e., octogenarians). DRG-based reimbursement would not be sensitive to these clinically important factors which have a major impact on outcomes and resource utilization.

Outcomes after abdominal aortic aneurysm repair: comparison of mortality defined by centralized VA Patient Treatment File data versus hospital-based chart review.

BACKGROUND: Outcomes after abdominal aortic aneurysm (AAA) repair have been reported by individual Veterans Affairs medical centers (VAMCs) and for the entire VA patient population. PURPOSE: This study was done to determine whether outcomes defined using VA Patient Treatment File (PTF) data were comparable to those defined by direct chart review in those undergoing repair of intact AAA. METHODS: Focused chart review was performed in all veterans undergoing such AAA repair in a sample of VAMCs (n = 5) for separate 1-year periods during fiscal years (FY) 1991-1993. A previous report of outcomes after AAA repair for all veterans in DRGs 110 and 111 during FY 1991-1993 was based on PTF data that were further analyzed by Patient Management Category (PMC) software. Outcomes after AAA repair were defined in a similar fashion using PTF data and PMC analysis in the same sample VAMCs for which direct chart review data were available. Outcomes defined by chart review were then compared to those based on PTF data. RESULTS: Three of the 69 patients undergoing repair of intact AAA for which chart review data were available were assigned to DRGs other than 110 and 111 and, by definition, were not included in the PTF-derived database. Nine of 10 additional patients undergoing chart review were not identified as having undergone AAA repair by PMC software: 7 had procedure codes 39.25 instead of more standard AAA repair codes 38.34 or 38.44. Two additional patients with codes 38.64 or 38.66 were not identified as having undergone AAA repair by PMC software. The 10th patient not included in the PTF-derived database underwent additional operative procedures. Of the 13 patients missed by the combined PTF and PMC outcome analyses but identified by chart review, none died or had cardiac complications. One of these 13 patients had pulmonary complications based on chart review and PTF but was excluded by PMC analysis. There remained a total of 56 patients at the five sample VAMCs common to the PTF-derived and chart-derived databases identified as having undergone repair of intact AAA. There were two in-hospital deaths in these patients, and both were identified by each approach to outcome assessment. Four of these 56 patients had postoperative cardiac complications (ICD-9-CM code 997. 10) which were identified by both PTF and chart review. Postoperative pulmonary complications (ICD-9-CM code 997.30) were present in 4 of the 56 cases and were also identified by both PTF-based and chart-based outcome analyses. CONCLUSIONS: All deaths as well as cardiac or respiratory complications identified by chart review at the study hospitals were also affirmed by the PTF. Due to study methodologies (which restricted analysis to those in DRGs 110 and 111 and which included secondary analyses of PTF data by PMC software), 19% of patients who underwent repair of intact AAA identified by hospital-based chart review were excluded from the PTF-based outcome analysis. Outcomes defined using large databases such as the VA PTF may be comparable to those defined by chart review if study methodologies permit. Discrepancies in outcome assessment between direct chart review and large database analysis in the present study were due to methodologies used, not to deficiencies, per se, in PTF data.

Duplex examination of the inferior vena cava.

Duplex examination of the inferior vena cava (IVC) was performed in 270 patients from 1/1/96 to 1/1/00 to define suitability of the IVC for caval interruption using noninvasive means. The IVC was interrogated using a 3-mHz curved linear array probe and an ATL Ultramark 9 ultrasound machine (Bothell, WA). Duplex measured IVC dimensions and defined presence of thrombus or anomalies. Of the 270 IVC duplex examinations 10.7 per cent (n = 29) could not be completed because of overlying bowel gas or for other technical reasons. Of the 241 completed studies 4.1 per cent (n = 10) revealed acute or chronic thrombosis of the IVC. The lateral diameter of the IVC was 20.3 +/- 4.4 mm (95% confidence interval 19.8-20.9 mm), whereas the anteroposterior diameter was 12.6 +/- 4.0 mm (95% confidence interval 12.1-13.1 mm). Excluding those with vena cava thrombosis maximum vena cava diameters exceeded 28 mm in only 2.2 per cent (n = 5) of those with technically adequate studies. Apart from the latter megacavas there were no major IVC anomalies detected. For those with incomplete studies body weight was 192 +/- 59 lb versus 169 +/- 38 lb for those with technically adequate studies (P = 0.008). Technically adequate vena cava duplex examinations can be performed in 89 per cent of patients. On the basis of this and one prior study done at this center IVC duplex can define vena cava dimensions and presence of thrombus. Using the standard criteria for IVC filter insertion that require presence of a maximum cava diameter < or = 28 mm and absence of caval thrombus or anomalies, 94 per cent (226 of 241) of those with complete duplex examinations would have been anatomically suitable for standard Greenfield filter insertion based on noninvasive testing.

Acute calf vein thrombosis: outcomes and implications.

The purpose of this study was to define the incidence of and outcomes associated with isolated acute calf vein thrombosis (CVT). From 11/95 through 6/97, 3096 patients underwent lower extremity venous duplex testing in a hospital-based vascular laboratory in which bilateral tibial and peroneal vein imaging were standard components of the venous duplex examination. CVT was present in 118 patients (3.8%), and 339 patients (10.9%) had acute proximal deep venous thrombosis (PDVT). Patients with CVT were 56.4+/-17.2 years of age (range, 18-92). Approximately 25 per cent with CVT had cancer (n = 30). Of the 18 patients with CVT who underwent ventilation-perfusion (V/Q) lung scanning, 56 per cent (n = 10) had high-probability scans. Venous duplex reports for those with CVT recommended follow-up venous duplex examination, which was done in 60 per cent (n = 71) of patients. Of the 71 patients with CVT who underwent follow-up testing, 15.5 per cent (n = 11) progressed to PDVT. The incidence of progression to deep venous thrombosis was 25 per cent (9 of 36) in those receiving anticoagulants at the time of initial venous duplex examination versus 5.7 per cent (2 of 35) in those not receiving anticoagulants (P = 0.046). With progression to PDVT, patients were more likely to have cancer (35% versus 7.8%; P = 0.009), more likely to have high-probability V/Q scans (36% versus 6.7%; P = 0.017), and more likely to die (27% versus 1.7%; P = 0.011) during follow-up. CVT was less common than proximal deep vein thrombosis and was also associated with pulmonary embolism. Progression of CVT was an adverse clinical event associated with greater chance of pulmonary embolism and death.

Pulmonary embolism in Veterans Affairs Medical Centers: is vena cava interruption underutilized?

Veterans with venous thrombosis or pulmonary embolism (PE) were evaluated using Veterans Affairs patient treatment file (PTF) data from fiscal years 1990-1995, inclusive, to define outcomes for those with PE. The specific aims of the study were to define how often those with PE underwent vena cava interruption (VCI) and whether VCI affected in-hospital mortality rates. Outcomes were defined using PTF data and Patient Management Category (PMC) software for 26,132 veterans discharged from all Veterans Affairs Medical Centers (VAMCs) with venous thromboembolism, which included a subset of 4,882 patients identified by both PTF data and PMC software to have PE. PMC software also generated measures of illness severity, patient complexity (PMC count), and resource utilization (called resource intensity scale) for each hospital admission. The in-hospital mortality rate for those with PE was 15.9 per cent (775 of 4882). Only 157 VCIs were performed in those with PE which constituted 3.2 per cent of the latter group. Those with PE who had VCI experienced a 13.4 per cent unadjusted in-hospital mortality rate (21 of 157) versus a 16 per cent unadjusted mortality rate without VCI (754/4725; not significant). In a logistic regression model of in-hospital mortality in those with PE, increasing age and illness severity were directly related to mortality, whereas VCI was independently associated with reduced mortality. The odds of death were reduced by 0.482 (0.287-0.807, 95% limits) for patients with PE who underwent VCI (P<0.005). Utilization of VCI varied among VAMCs: the hospital rates that VCI were performed in those with PE ranged from 0 to 16.7 per cent. Mortality associated with PE was substantial in VAMCs, and VCI was independently associated with reduced in-hospital mortality. The low percentage of veterans with pulmonary embolism who underwent VCI was surprising. VCI may be underutilized in veterans with PE.

Acute mesenteric ischemia.

Acute mesenteric ischemia (AMI) remains a complex and difficult clinical problem. Such acute ischemia is usually either embolic or thrombotic in nature, but other etiologies exist. The diagnosis of AMI is difficult to establish and often delayed, resulting in irreversible bowel injury that requires intestinal resection. Mortality for AMI remains high, and patients requiring extensive gut resection are unlikely to survive. Patients surviving intestinal resection may develop short gut syndrome. The prognosis dramatically improves if revascularization can be achieved prior to intestinal infarction.

Effects of autonomic neuropathy on coronary blood flow in patients with diabetes mellitus.

BACKGROUND: C ardiac sympathetic signals play an important role in the regulation of myocardial perfusion. We hypothesized that sympathetically mediated myocardial blood flow would be impaired in diabetics with autonomic neuropathy. METHODS AND RESULTS: We studied 28 diabetics (43+/-7 years old) and 11 age-matched healthy volunteers. PET was used to delineate cardiac sympathetic innervation with [(11)C]hydroxyephedrine ([(11)C]HED) and to measure myocardial blood flow at rest, during hyperemia, and in response to sympathetic stimulation by cold pressor testing. The response to cardiac autonomic reflex tests was also evaluated. Using ultrasonography, we also measured brachial artery reactivity during reactive hyperemia (endothelium-dependent dilation) and after sublingual nitroglycerin (endothelium-independent dilation). Based on [(11)C]HED PET, 13 of 28 diabetics had sympathetic-nerve dysfunction (SND). Basal flow was regionally homogeneous and similar in the diabetic and normal subjects. During hyperemia, the increase in flow was greater in the normal subjects (284+/-88%) than in the diabetics with SND (187+/-80%, P=0.084) and without SND (177+/-72%, P=0.028). However, the increase in flow in response to cold was lower in the diabetics with SND (14+/-10%) than in those without SND (31+/-12%) (P=0.015) and the normal subjects (48+/-24%) (P<0.001). The flow response to cold was related to the myocardial uptake of [(11)C]HED (P<0.001). Flow-mediated brachial artery dilation was impaired in the diabetics compared with the normal subjects, but it was similar in the diabetics with and without SND. CONCLUSIONS: Diabetic autonomic neuropathy is associated with an impaired vasodilator response of coronary resistance vessels to increased sympathetic stimulation, which is related to the degree of SND.

Aortocaval fistula: diagnosis with carbon dioxide angiography.

Aortocaval fistulas are an uncommon complication of atherosclerotic aneurysms that can present with a variety of clinical symptoms. Many of these patients present with oliguric renal failure, a contraindication for the use of iodinated contrast in radiological studies. We present a case of an aortocaval fistula diagnosed by using carbon dioxide gas without the use of traditional contrast media.

Cervical reconstruction of the supra-aortic trunks: a 16-year experience.

PURPOSE: The purpose of this study was to review 182 consecutive cervical reconstructions of supra-aortic trunks, which were performed over a 16-year period. METHODS: A total of 182 innominate, common carotid, or subclavian arteries were reconstructed with a cervical approach in 173 patients aged 23 days to 83 years. Indications included hemispheric (n = 79), vertebrobasilar (n = 56), upper extremity (24), and internal mammary/cardiac ischemia (n = 5), asymptomatic severe common carotid disease (n = 33), or other (n = 3). Primary atherosclerotic innominate (n = 6), common carotid (n = 84), and subclavian (n = 66) lesions underwent reconstruction. Thirty-one operations were performed for multiple trunk involvement, recurrent disease, arteritis, infection, dissection, coarctation, or aneurysm. There were 122 bypass grafting procedures (98 ipsilateral, 24 contralateral) and 60 arterial transpositions. RESULTS: One death (0.5%) and 7 nonfatal strokes (3.8%) occurred, none in patients who were asymptomatic. Perioperative morbidity included four asymptomatic occlusions (2%), 6 myocardial infarctions (3%), 10 pulmonary complications (5%), and 2 graft infections (1%). Follow-up periods ranged from 1 to 190 months (mean, 53 +/- 5 months). Nineteen patients (10%) were lost to follow-up. Fifty-seven late deaths occurred, most from cardiac causes. Seven reconstructions necessitated late revision. The cumulative primary patency rate at 5 and 10 years was 91% +/- 2% and 82% +/- 5%, respectively. The survival rate at 5 years was 72% +/- 4% and at 10 years was 41% +/- 6%. The stroke-free survival rate was 92% +/- 2% at 5 years and 84% +/- 2% at 10 years. CONCLUSION: Cervical reconstruction of symptomatic and asymptomatic supra-aortic trunk lesions carries acceptable death and stroke rates and provides a long-term patient benefit. This should be the preferred approach for asymptomatic lesions and for patients with significant comorbidity because it carries less morbidity than direct transmediastinal aortic-based reconstruction.

Health status in veterans undergoing noninvasive lower extremity arterial evaluation.

The health status of outpatients (n = 299) undergoing lower extremity arterial Doppler studies (LES) in a Veterans Affairs Medical Center-based vascular laboratory was assessed from 9/95 through 6/96 using the SF-36 Health Survey. The purpose of this study was to compare health status of these outpatients to national norms and to determine whether Doppler-derived ankle/brachial indices (ABI) correlated with the eight health concepts measured by the SF-36 Health Survey. Physical functioning (PF), role limitations by physical illness (RP), bodily pain (BP), general health (GH), vitality (VT), social functioning (SF), role limitations by emotional illness (RE), and mental health (MH) were more impaired in study patients (65.9 +/- 9.6 years of age) undergoing LES than national norms for males >/=65 years old (P < 0.0001). In fact, each health concept was below the 25th percentile of the national norms. PF was 33.4 +/- 22.4 for outpatients compared to the national norm of 65.8 +/- 28.3. Physical functioning was the only SF-36 health concept defined above which correlated with lowest ABI (r = 0.15; P = 0.012), adjusting for age but not comorbidities. Veterans undergoing only carotid duplex during the study period (n = 169) were compared to the veterans undergoing only LES (n = 251) during the study. PF, RP, BP, GH, VT, SF, and RE were significantly more impaired in those undergoing only LES compared with carotid duplex (P < 0.05). Veteran outpatients referred to a vascular laboratory have broad-based and profound impairments in health status. In addition, only physical functioning correlated with ABI, a measure of lower extremity arterial disease severity.

Carotid surgery in octogenarians in Veterans Affairs medical centers.

The purpose of this study was to define outcomes after carotid surgery in octogenarians in the Veterans Affairs health care system. During fiscal years 1991-1994, 9152 patients in DRG 5 underwent extracranial vascular surgery procedures in Veterans Affairs medical centers. Those >/=80 years of age constituted 2.1% (n = 195) of such patients. In-hospital mortality rates were 1.03% (92/8957) in those <80 versus 3.08% (6/195) in those >/=80 years old (P = 0.018). Of those >/=80, 11.8% (23/195) had an ICD-9-CM-coded complication during hospitalization versus 11.2% of those <80 (1004/8957, NS). Surgical complications of the central nervous system (CNS) were present in 0.51% of octogenarians (1/195) and in 0.93% of those younger (83/8957, NS). Myocardial infarction (MI) occurred in 1.0% (2/195) of octogenarians and 0.74% (66/8967) of younger patients (NS). Patient Management Category software was used to define illness severity and resource intensity scale (RIS, a measure of resource utilization). Logistic regression analysis showed that age, illness severity, MI, and surgical complications of the CNS were associated with greater likelihood of mortality after extracranial vascular surgery. When the dichotomous variable "octogenarian status" was substituted for the continuous variable "age," in this model, there was no significant association of octogenarian status per se with mortality, though the association of illness severity, MI, and CNS complications with mortality persisted. Illness severity was greater for octogenarians (2.03 +/- 1.36) versus those younger (1.84 +/- 1.13, P < 0.05). RIS was 2.57 +/- 0.57 in octogenarians versus 2.47 +/- 0.48 for younger patients (P < 0.015). Length of stay (LOS) was a mean of 3.2 days longer for octogenarians (P < 0. 001). The risk of postoperative CNS complications was not higher in octogenarians. Mortality, resource utilization, and length of stay were, however, greater for octogenarians, but so was illness severity. Though mortality rates were greater for octogenarians in DRG 5, illness severity, MI, and postoperative CNS complications had greater impact on mortality after extracranial vascular surgery than octogenarian status per se.

Outcomes after abdominal aortic aneurysm repair in those > or =80 years of age: recent Veterans Affairs experience.

During fiscal years 91-95, 6260 patients underwent 6269 abdominal aortic aneurysm (AAA) repairs in Veterans Affairs Medical Centers. Those > or =80 years old comprised 3.7% (n = 231) of the patients. A total of 5833 patients underwent repair of nonruptured AAA: mortality was 4.1% (228/5627) in those <80 and 8.25% (17/206) in those > or =80 years old (p < 0.009). Logistic regression analysis indicated age > or =80 was independently associated with higher mortality (odds ratio 1.834:1, 95% bounds 1.117-3.012). Octogenarian status (defined as > or =80 years of age), however, had a less important association with in-hospital death than did surgical complications of the heart or genitourinary tract, postoperative hemorrhage, septicemia, respiratory insufficiency, myocardial infarction (MI), acute renal failure, surgical complications of the central nervous system (CNS), aneurysm rupture, postoperative shock, or disseminated intravascular coagulation (DIC), in ascending order of importance. Only 5.9% (n = 25) of the 427 patients undergoing repair of ruptured AAA were > or =80 years old. In those > or =80 undergoing repair of ruptured aneurysms, mortality was 48% which did not differ from the 45% mortality in those <80 (NS). The likelihood that one would be operated for rupture was statistically greater (1.66:1) for those > or =80 years (p < 0.025). Length of stay (LOS) for those > or =80 undergoing AAA repair was longer being 22.3 +/- 14.8 days versus 18.3 +/- 13.2 days for younger patients (p < 0.001). Mortality and LOS after AAA repair were statistically greater for those > or =80 years of age. Severity of illness, however, was also greater for octogenarians. Patient Management Category (PMC) software defined illness severity was 4.06 +/- 1.22 in octogenarians versus 3.84 +/- 1.13 for those younger (p < 0.005). Though age > or =80 was independently associated with increased mortality, selected elderly patients could benefit from AAA repair.