Geographic disparities in perioperative and mid-term outcomes after elective infrarenal endovascular aneurysm repair
Objective: This study aimed to assess the impact of geographic location on mid-term postoperative outcomes after endovascular aneurysm repair (EVAR) across four Canadian tertiary care institutions. We hypothesized that patients from rural or nonlocal areas may experience worse perioperative outcomes...
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| Main Authors: | , , , |
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| Format: | Article |
| Language: | English |
| Published: |
Elsevier
2025-01-01
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| Series: | JVS-Vascular Insights |
| Subjects: | |
| Online Access: | http://www.sciencedirect.com/science/article/pii/S2949912725000704 |
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| Summary: | Objective: This study aimed to assess the impact of geographic location on mid-term postoperative outcomes after endovascular aneurysm repair (EVAR) across four Canadian tertiary care institutions. We hypothesized that patients from rural or nonlocal areas may experience worse perioperative outcomes because of loss to follow-up, care transfers, and suboptimal surveillance. These factors could contribute to increased nonindex readmissions and higher mortality rates after elective EVAR. Methods: Elective infrarenal EVAR patients from four Canadian tertiary care institutions were assessed through a retrospective analysis of the Vascular Quality Initiative (VQI) database, stratified by rural vs urban postal codes. A subgroup analysis was also conducted using a 10-year retrospective dataset from Toronto General Hospital and the VQI to evaluate EVAR outcomes based on patient geography. Primary outcomes included differences in loss to follow-up, overall survival, and reintervention-free survival. Secondary outcomes included differences in baseline characteristics, perioperative outcomes, and imaging surveillance. Statistical analyses consisted of t-tests for continuous variables, χ2 tests for categorical variables, and Kaplan-Meier survival analysis with log-rank tests. Results: Elective EVAR outcomes from four Canadian hospitals (n = 1342 patients) were analyzed by rural vs urban status. Rural patients demonstrated higher postoperative imaging rates, but were more likely to be lost to follow-up. Aggregate data revealed a survival advantage for urban patients at 12 months postoperatively. A subgroup analysis from a single tertiary care institution included 491 patients who underwent elective infrarenal EVAR. Patients were categorized by postal code as local vs nonlocal (80.9% and 19.1%, respectively) and urban vs rural (94.9% and 5.1%, respectively). The median follow-up duration was 32 months (interquartile range, 51 months). Local and urban patients had significantly higher rates of follow-up within the first 2 months (local, 84.6% vs nonlocal, 57.4% [P < .001]; urban, 80.2% vs rural, 64.0% [P = .050]) and more frequent imaging between 6 and 12 months (local, 69.5% vs nonlocal, 43.6% [P < .001]; urban, 65.9% vs rural, 40.0% [P = .008]). However, survival analysis did not demonstrate significant differences in estimated mean postoperative survival between groups (urban, 9.19 years vs rural, 9.87 years [P = .162]; local, 9.15 years vs nonlocal, 9.72 years [P = .219]). Conclusions: At the national level, four Canadian VQI centers demonstrated higher rates of loss to follow-up and lower 1-year survival among patients from rural communities. In contrast, a subgroup analysis from our institution revealed that rural and nonlocal patients received fewer follow-up appointments and underwent less postoperative imaging; however, no significant differences in mortality or reintervention were observed. The influence of geographic distance and rurality status on follow-up and imaging highlights a potential vulnerability to aneurysm-related mortality, warranting further investigation. |
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| ISSN: | 2949-9127 |