International variations in infrainguinal bypass surgery – a VASCUNET report

OBJECTIVES:

To compare practice in lower limb bypass surgery in nine countries.

DESIGN:

A prospective study amalgamating and analysing data from national and regional vascular registries.

METHODS:

A table of data fields and definitions was agreed by all member countries of the Vascunet Collaboration. Data from January 2005 to December 2009 was submitted to a central database.

RESULTS:

32,084 cases of infrainguinal bypass (IIB) in nine countries were analysed. Procedures per 100,000 population varied between 2.3 in the UK and 24.6 in Finland. The proportion of women varied from 25% to 43.5%. The median age for all countries was 70 for men and 76 for women. Hungary treated the youngest patients. IIB was performed for claudication for between 15.7% and 40.8% of all procedures. Vein grafts were used in patients operated on for claudication (52.9%), for rest pain (66.7%) and tissue loss (74.1%). Italy had the highest use of synthetic grafts. Among claudicants 45% of bypasses were performed to the below knee popliteal artery or more distally. Graft patency at 30 days varied between 86% and 99%.

CONCLUSIONS:

Significant variations in practice between countries were demonstrated. These results should be interpreted alongside the known limitations of such registry data with respect to quality and completeness of the data. Variation in data completeness and data validation between countries needs to be improved for useful international comparison of outcomes.

Link: https://www.ncbi.nlm.nih.gov/pubmed/22658613

Variation in clinical practice in carotid surgery in nine countries 2005-2010. Lessons from VASCUNET and recommendations for the future of national clinical audit

OBJECTIVES:

The aim of the study was to analyse variation in carotid surgical practice, results and effectiveness in nine countries.

PATIENTS AND METHODS:

A total of 48,185 carotid endarterectomies (CEAs) and 4602 carotid artery stenting (CAS) procedures were included in the comparison. A theoretical effectiveness of CEA provision for each country was estimated.

RESULTS:

92.6% of the CEAs were performed according to the inclusion criteria based on the current European recommendations and had a theoretical benefit for the patient. The indication for surgery was symptomatic stenosis in 60.1% and this proportion varied between 31.4% in Italy and 100% in Denmark. The overall combined stroke and death rate in symptomatic patients was 2.3%. This varied between rates of 0.9% in Italy and 3.8% in Norway. The overall combined stroke and death rate in asymptomatic patients was 0.9%. It was lowest in Italy at 0.5%, and highest in Sweden at 2.7%. We estimated that the stroke prevention rate per 1000 CEAs varied from 72.9 in Italy to 130.8 in Denmark.

CONCLUSIONS:

There is significant variation in clinical practice across the participating countries. The theoretical stroke prevention potential of CEA seems to vary between participating countries due to differences in the inclusion criteria.

Link: https://www.ncbi.nlm.nih.gov/pubmed/22633072

Treatment of abdominal aortic aneurysm in nine countries 2005-2009: a vascunet report

OBJECTIVES:

To study contemporary treatment and outcome of abdominal aortic aneurysm (AAA) repair in nine countries.

DESIGN AND METHODS:

Data on primary AAA repairs 2005-2009 were amalgamated from national and regional vascular registries in Australia, Denmark, Finland, Hungary, Italy, Norway, Sweden, Switzerland and the UK. Primary outcome was in-hospital or 30-day mortality. Multivariate logistic regression was used to assess case-mix.

RESULTS:

31,427 intact AAA repairs were identified, mean age 72.6 years (95% CI 72.5-72.7). The rate of octogenarians and use of endovascular repair (EVAR) increased over time (p < 0.001). EVAR varied between countries from 14.7% (Finland) to 56.0% (Australia). Overall perioperative mortality after intact AAA repair was 2.8% (2.6-3.0) and was stable over time. The perioperative mortality rate varied from 1.6% (1.3-1.8) in Italy to 4.1% (2.4-7.0) in Finland. Increasing age, open repair and presence of comorbidities were associated with outcome. 7040 ruptured AAA repairs were identified, mean age 73.8 (73.6-74.0). The overall perioperative mortality was 31.6% (30.6-32.8), and decreased over time (p = 0.004).

CONCLUSIONS:

The rate of AAA repair in octogenarians as well as EVAR increased over time. Perioperative outcome after intact AAA repair was stable over time, but improved after ruptured repair. Geographical differences in treatment of AAA remain.

Link: https://www.ncbi.nlm.nih.gov/pubmed/21775173

Outcome following carotid endarterectomy: lessons learned from a large international vascular registry

OBJECTIVES:

The aim of the study was to assess if technical and patient-related factors are related to outcome after carotid surgery.

DESIGN:

Vascunet is a collaboration of national and regional registries with 10 contributing countries.

PATIENTS AND METHODS:

Data from 48,035 carotid endarterectomies (CEAs) performed in 383 centres, during 2003-2007, were merged into a common database.

RESULTS:

CEA was performed without patch (34%), with patch (40%) or with eversion (26%) in 74% for symptomatic and in 26% for asymptomatic disease. Overall (in-hospital and 30-day) mortality was 0.45%. Type of CEA or anaesthesia did not affect mortality, nor did contralateral occlusion. Mortality was higher in patients above the age of 75 years, for both genders (p < 0.05). The overall (in-hospital) stroke rate was 1.9%, the method of anaesthesia did not affect stroke rate. It was higher in patients with contralateral occlusion (4.6% vs. 2.5%, p = 0.002). Standard CEA without patch had a higher stroke rate than when a patch was used (2.3 vs. 1.7%, p = 0.015). Female patients >75 years had a higher stroke rate than younger women (2.0% vs. 1.6%, p = 0.078); this difference was not observed in men.

CONCLUSIONS:

Although there are limitations with registry data, the large number of cases involved provides useful information on outcomes, supplementing data from the randomised clinical trials (RCTs).

Link: https://www.ncbi.nlm.nih.gov/pubmed/21450496