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Skjoth F, Larsen TB, Rasmussen LH. Indirect comparison studies—are they useful? Insights from the novel oral anticoagulants for stroke prevention in atrial fibrillation. Thromb Haemost 2012; 108: 405–06. Kansal AR, Sharma M, Bradley-Kennedy C, et al. Dabigatran versus rivaroxaban for the prevention of stroke and systemic embolism in atrial fibrillation in Canada. Comparative efficacy and cost-effectiveness. Thromb Haemost 2012; 108: 672–82. Larsen TB, Rasmussen LH, Skjoth F, et al. Efficacy and safety of dabigatran etexilate and warfarin in “real-world” patients with atrial fibrillation: a prospective nationwide cohort study. J Am Coll Cardiol 2013; 61: 2264–73. Gallagher AM, Setakis E, Plumb JM, Clemens A, van Staa TP. Risks of stroke and mortality associated with suboptimal anticoagulation in atrial fibrillation patients. Thromb Haemost 2011; 106: 968–77.

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Gallego P, Roldan V, Marin F, et al. Cessation of oral anticoagulation in relation to mortality and the risk of thrombotic events in patients with atrial fibrillation. Thromb Haemost 2013; published online Oct 7. http:// dx.doi.org/10.1160/TH13-07-0556. Apostolakis S, Sullivan RM, Olshansky B, Lip GY. Factors affecting quality of anticoagulation control among patients with atrial fibrillation on warfarin: the SAMe-TT2R2 score. Chest 2013; 144: 1555–63. Boriani G. Predicting the quality of anticoagulation during warfarin therapy: the basis for an individualized approach. Chest 2013; 144: 1437–38.

Improving outcomes for ruptured abdominal aortic aneurysm

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for improvement of perioperative mortality when compared with open repair.6 Two recently published randomised trials have, however, failed to document any difference in short-term survival based on surgical technique.7,8 Karthikesalingam and colleagues’ study1 suggests that the main benefit of EVAR for rAAA might be the possibility to treat elderly patients, patients with comorbidities, or both, who would not otherwise be considered candidates for open surgery. This international trend is clear in the elective setting; as an example, the broad introduction of EVAR has resulted in a more than doubled incidence of elective AAA repair among octogenarians in Sweden.3 Additionally, treatment of patients with rAAA at specialised centres with extensive experience of vascular surgery results in an increasing acceptance to treat high-risk patients.9 This increased acceptance might not necessarily reduce perioperative mortality,

See Articles page 963

Sapone, Patti/Star Ledger/Corbis

Ruptured abdominal aortic aneurysm (rAAA) is a common cause of death in the elderly western population. In The Lancet, Alan Karthikesalingam and colleagues’ study1 shows important differences between the USA and England in treatment of this fatal disease, and variations in survival rate that are dependent on treatment strategy and surgical activity. Karthikesalingam and colleagues used the Hospital Episode Statistics for England and the Nationwide Inpatient Sample for the USA to compare data for patients admitted to hospital with rAAA during 2005–10. Open or endovascular surgery was offered to a greater proportion of American patients than English patients (19 174 [80·43%] vs 6897 [58·45%]), and endovascular aneurysm repair (EVAR) was more common in the USA than in England (4003 [20·87%] vs 589 [8·54%]), resulting in a lower in-hospital mortality in the USA than in England (53·05% [95% CI 51·26–54·85] vs 65·90%). This international benchmarking of results of rAAA repair serves as an excellent basis for improving quality of care of these patients. Previous national and international studies have documented improvement in outcome of rAAA repair in past decades.2–4 These studies have, however, focused on perioperative outcome, disregarding the patients with rAAA who were not offered surgical treatment. The proportion of patients with rAAA in the UK who are offered surgery has been stable during the past decade.5 The more active treatment of aortic rupture in the USA than in England, shown by the present study, is mainly linked to increased centralisation and availability of EVAR. Much focus has been on the role of minimally invasive EVAR in treatment of rAAA, and the potential

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but can reduce the overall mortality in rAAA, because non-surgical treatment always leads to death. Although surgical treatment improves short-term survival in these patients, the study1 does not take a long-term perspective on outcomes. With modern intensive care, many patients with rAAA do survive the early postoperative period, but fail to recover fully. This is shown by the fact that mortality remains high up to 90 days following surgery after rAAA.10 Karthikesalingam and colleagues’ study1 only assesses in-hospital mortality, and reports that patients are discharged earlier in the USA than in the UK. This could affect the validity of the study’s results; an assessment of at least 90-day, and preferably 1-year, outcomes after rAAA would be more informative. The main limitation of Karthikesalingam and colleagues’ study1 is linked to the study of in-hospital mortality. Referral patterns between hospitals might differ between the two countries, as could recognition and registration of patients who did not undergo surgery. A validation of these aspects in two registries, studying a sample of patients, would have added robustness to the investigation. Another limitation is that preoperative diagnostic activity, and frequency of post-mortem examinations, might differ between the countries, and these potential confounders were not assessed. A patient who dies suddenly might be misclassified if the necessary investigations are not done. The reported differences between the countries are so great, however, that the conclusions would probably not have been changed even if these issues had been addressed. It is well known that rAAA is difficult to investigate, and the authors are to be commended for a study of great quality and clinical importance. The study1 underlines the importance of national and international audits as a measure to achieve quality improvement in health care. The UK vascular surgical community is to be commended, because it has successfully conducted a quality improvement programme for AAA. This effort was initiated on the basis of an international comparison of perioperative mortality after elective AAA repair, and resulted in significant improvement of results.4 The current USA versus England comparison of rAAA treatment should initiate further discussions on how to optimise services for treatment of this fatal disease. 934

As for most diseases, prevention is the key to success. Vascular surgeons in the UK have organised the largest randomised clinical trial of ultrasound screening of elderly men for AAA, the MASS trial.11 The 13-year results showed that all-cause mortality was reduced by 3% (95% CI 1–5) in the entire population invited to screening, an extraordinary result.11 England and Sweden now have national coverage of ultrasound screening for men aged 65 years,12,13 and other countries are following. Prevention will prolong the lives of many more patients with AAA in the future than efforts to improve treatment of ruptured AAA. In the meantime, however, while awaiting the full effect of the AAA screening programmes, work is to be done to improve survival of patients who have rAAA. *Martin Björck, Kevin Mani Department of Surgical Sciences, Uppsala University, SE 751 85 Uppsala, Sweden [email protected] We declare that we have no competing interests. 1

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Karthikesalingam A, Holt PJ, Vidal-Diez A, et al. Mortality from ruptured abdominal aortic aneurysms: clinical lessons from a comparison of outcomes in England and the USA. Lancet 2014; 383: 963–69. Bown MJ, Sutton AJ, Bell PR, Sayers RD. A meta-analysis of 50 years of ruptured abdominal aortic aneurysm repair. Br J Surg 2002; 89: 714–30. Mani K, Bjorck M, Wanhainen A. Changes in the management of infrarenal abdominal aortic aneurysm disease in Sweden. Br J Surg 2013; 100: 638–44. Mani K, Lees T, Beiles B, et al. Treatment of abdominal aortic aneurysm in nine countries 2005–2009: a Vascunet report. Eur J Vasc Endovasc Surg 2011; 42: 598–607. Anjum A, Powell JT. Is the incidence of abdominal aortic aneurysm declining in the 21st century? Mortality and hospital admissions for England & Wales and Scotland. Eur J Vasc Endovasc Surg 2012; 43: 161–66. Veith FJ, Lachat M, Mayer D, et al. Collected world and single center experience with endovascular treatment of ruptured abdominal aortic aneurysms. Ann Surg 2009; 250: 818–24. Powell JT, Sweeting MJ, Thompson MM. Endovascular or open repair strategy for ruptured abdominal aortic aneurysm: 30 day outcomes from IMPROVE randomised trial. BMJ 2014; 348: f7661. Reimerink JJ, Hoornweg LL, Vahl AC, et al. Endovascular repair versus open repair of ruptured abdominal aortic aneurysms: a multicenter randomized controlled trial. Ann Surg 2013; 258: 248–56. Basnyat PS, Biffin AH, Moseley LG, Hedges AR, Lewis MH. Mortality from ruptured abdominal aortic aneurysm in Wales. Br J Surg 1999; 86: 765–70. Mani K, Bjorck M, Lundkvist J, Wanhainen A. Improved long-term survival after abdominal aortic aneurysm repair. Circulation 2009; 120: 201–11. Thompson SG, Ashton HA, Gao L, Buxton MJ, Scott RAP, on behalf of the Multicentre Aneurysm Screening Study (MASS) Group. Final follow-up of the Multicentre Aneurysm Screening Study (MASS) randomized trial of abdominal aortic aneurysm screening. Br J Surg 2012; 99: 1649–56. Stather PW, Dattani N, Bown MJ, Earnshaw JJ, Lees TA. International variations in AAA screening. Eur J Vasc Endovasc Surg 2013; 45: 231–34. Svensjö S, Bjorck M, Gürtelschmid M, Djavani Gidlund K, Hellberg A, Wanhainen A. Low prevalence of abdominal aortic aneurysm among 65-year old Swedish men challenges current screening guidelines. Circulation 2011; 124: 1118–23.

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Improving outcomes for ruptured abdominal aortic aneurysm.

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