Advancing management of aortic aneurysm disease

Part I focusses on the value of aortic aneurysm repair database research. As many administrative data and quality improvement registries are widely available and easily accessible, an understanding of the appropriate use is essential. Part I contributes to the quality improvement of database research by increasing the understanding of the value, specific characteristics, strengths, and limitations of databases and database research. Chapter 2 provides an overview of specific paradigm shift in AAA management driven by database outcomes research and describes challenges and opportunities. Chapter 3 contains a comparison of the national insample (NIS) database, national surgical quality improvement program (NSQIP) registry, and vascular quality initiative (VQI) registry using AAA repair as a lens. Risk scores provide tools to patients and healthcare providers. In chapter 4, we utilized the NIS, VQI, and NSQIP, to compare the ability of the risk scores to assess in-hospital mortality based on available preoperative characteristics. Hereby rethinking quality metrics and emphasizing on the importance of understanding the characteristics of different databases. In Part II “management of AAA in specific subpopulations” we focus on quality improvement in AAA management across diverse populations. Previous research shows differences in AAA prevalence, management, and outcomes across sex, racial, and ethnic groups. In most AAA studies the results are driven by white and male populations and these results might not be representative for female or nonwhite patients. By understanding these variations and identifying sex and race specific areas for quality improvement we can ensure that outcomes of AAA repair improve over time for all patients. Chapter 5 evaluates the association of female sex and perioperative outcomes after endovascular and open complex AAA repair. Several studies have found that female patients have smaller aortic diameter at the time of repair for both intact and ruptured AAA compared with male patients.9–12 Therefore, in chapter 6 we propose sex-specific thresholds for AAA repair using aortic diameter, aortic size index, and aortic height index. In chapter 7 we seek to describe racial differences in aortoiliac aneurysm repair and identify targeted areas of quality improvement to reduce these disparities. In Part III “practice patterns and appropriate application of EVAR”, challenges and opportunities of endovascular repair are discussed. The evolution of AAA management has been strongly tied to technological advancement. Therefore, continuously reassessing the current approach and areas for quality improvement is essential. Long-term outcomes after large AAA repair are compared to smaller AAA repair in chapter 8, stratified by endovascular and open repair. Chapter 9 focusses on long-term implication of compliance to the guideline recommended diameter threshold for elective EVAR. In chapter 10 the adherence to device instruction for use and association with outcomes in elective AAA repair is examined