Patients Now Being Asked to Choose Open or Endoscopic
By Annette M. Boyle
WHITE RIVER JUNCTION, VT—Each year, about 2,000 veterans have surgery for abdominal aortic aneurysms. Over the past two decades, a rising percentage of those surgeries have been endoscopic rather than open, as surgeons have assumed that patients would prefer the quicker recovery associated with the less-invasive procedure.
Now, they might not be as sure. A new study has recently begun to find out how to best align veterans’ actual preferences with the kind of surgery they have.
Abdominal aortic aneurysms (AAA) develop when the walls of the lower part of the aortic artery weaken, leading first to a bulge. “Because those weakenings can develop into ruptures, often a fatal event for veterans, we try to address them before that happens,” explained lead investigator Philip Goodney, MD, co-director of the VA Outcomes Group based at the White River Junction (VT) VAMC.
As nearly 10,000 Americans die from AAA ruptures each year, there is little debate about the need for surgery for large, rapidly expanding or symptomatic aneurysms. Instead, the controversy surrounds the type of surgery.
Goodney estimated that 30-40% of veterans have open surgery today, and 60-70% have endovascular repair, although the rates vary by hospital and the distance that veterans come for treatment.
The classic, open surgery involves a significant abdominal incision to emplace a prosthetic graft to reinforce the aorta.
“It’s a big operation, which often necessitates time in intensive care and has significant upfront risk,” Goodney told U.S. Medicine. Those risks can include heart attack, lung problems, kidney damage and blood clots during and immediately after the procedure.
About 5% of patients die during the surgery in the 30 days immediately following, according to University of Michigan research. Recovery can take two to three months.
But, Goodney noted, there are few complications after patients recover. Most patients who have open surgery have a follow-up visit at one month and have imaging done about five years after the surgery. Minor problems such as hernias sometimes occur, “but you don’t die from them,” he said. “It’s not quite ‘fix it and forget it,’ but it is much less intensive” than endovascular aneurysm repair.
Endovascular aneurysm repair (EVAR) involves two small incisions in the groin, through which a stent is placed to bridge the weak part of the artery. Patients can typically go home the next day and resume their regular activities in a week or two. Problems frequently occur after recovery, however.
“The stent might degenerate; the artery might degenerate; tiny arteries might leak back in. It adds up to trouble as the years go by,” Goodney said. “Because of the risk of leaks, patients who have this type of repair need to come back once or twice a year to have imaging. If any leaks are present, they need to come more often.” Ultimately, 10-20% of EVAR patients have to have repairs, he noted.
“It’s not uncommon for a veteran to live some distance from a medical center or not to be enthusiastic about coming to see a doctor twice a year for the rest of their lives. We hear pretty consistently that surveillance anxiety negatively affects them. We didn’t realize that no one had asked veterans their preference before the surgery,” Goodney said.
Now, patients are being asked. The Preference for Open Versus Endovascular AAA Repair (PROVE-AAA) study received $1.1 million to find out whether veterans are getting the surgery they want.
The four-year study will involve 240 patients with abdominal aortic aneurysms of at least five centimeters who are eligible for both types of surgery, 12 each at 20 sites. The veterans will be asked to rate several factors that might affect which surgery they prefer. Those factors include how important it is for them to leave the hospital quickly, not worry about leaks later or minimize follow-up visits. At half the centers, veterans also will receive a booklet that presents the advantages and disadvantages of both types of surgery in plain language, while, at the other 10, they will not. Patients will be followed for two years.
“We hope to find out what considerations are associated with the preference for one type of surgery or the other,” Goodney stated. The researchers anticipate that veterans who value durability and live further from medical centers will prefer open surgery, while those with concerns about pain or lengthy recovery times will choose the endovascular option.
In addition, “we hypothesize that veterans who receive the booklet will have a better discussion about their choices and get treatment that is more aligned with their preferences,” Goodney added. The researchers will analyze how often veterans have the procedure their surveys indicate they would prefer at the control sites compared with the veterans who used the decision aid.
In keeping with U.S. Preventive Services Task Force recommendations, the VA advises all men between the ages of 65 and 75 who have ever smoked cigarettes to be screened for abdominal aortic aneurysms. Men are twice as likely as women to have AAA and those who have ever smoked have three to five times the risk of never-smokers.
Legislation that would streamline VA’s community care programs into one program and expand VA’s caregiver program to veterans of all eras was signed into law earlier this month..
The good news from a recent consultant study is that, overall, the VA healthcare system is generally equal or better than others when inpatient and outpatient quality is measured.