Preoperative anemia is a risk factor for worse 30-day outcomes in both open and endovascular repair of non-ruptured infrarenal abdominal aortic aneurysm

Abstract

Background

Anemia is a highly prevalent condition potentially linked to chronic inflammation. Preoperative anemia is an independent risk factor across many surgical fields. However, the relationship between anemia and abdominal aortic aneurysm (AAA) repair outcomes remains unclear. This study aimed to examine the effects of preoperative anemia on 30-day outcomes of non-ruptured infrarenal AAA repair.

Methods

Patients who underwent open surgical repair (OSR) and endovascular aneurysm repair (EVAR) for infrarenal AAA were identified in National Surgical Quality Improvement Program (NSQIP) targeted databases from 2012 to 2021. Anemia was defined as preoperative hematocrit less than 39% in males and 36% in females. Multivariable logistic regression was used to compare 30-day perioperative outcomes between anemic and non-anemic patients, adjusting for demographics, comorbidities, indications, aneurysm extents, operation time, and surgical approaches.

Results

There were 408 (22.13%) anemic and 1436 (77.88%) non-anemic patients who underwent OSR for non-ruptured AAA, while 3586 (25.20%) patients with and 10,644 (74.80%) without anemia underwent EVAR. In both OSR and EVAR, anemic patients had higher risks of bleeding requiring transfusion (OSR, aOR = 2.446, p < .01; EVAR, aOR = 3.691, p < .01), discharge not to home (OSR, aOR = 1.385, p = .04; EVAR, aOR = 1.27, p < .01), and 30-day readmission (OSR, aOR = 1.99, p < .01; EVAR, aOR = 1.367, p < .01). Also, anemic patients undergoing OSR had higher pulmonary events (aOR = 2.192, p < .01), sepsis (aOR = 2.352, p < .01), and venous thromboembolism (aOR = 2.913, p = .01), while in EVAR, anemic patients had higher mortality (aOR = 1.646, p = .01), cardiac complications (aOR = 1.39, p = .04), renal dysfunction (aOR = 1.658, p = .02), and unplanned reoperation (aOR = 1.322, p = .01). Moreover, in both OSR and EVAR, anemic patients had longer hospital length of stay (p < .01).

Conclusion

In OSR and EVAR, preoperative anemia was independently associated with worse 30-day outcomes. Preoperative anemia could be a useful marker for risk stratification for patients undergoing infrarenal AAA repair.

Keywords

Anemia abdominal aortic aneurysm EVAR open surgery hematocrit

Get full access to this article

View all access options for this article.

References

Zhao

Zhang

, et al. Prevalence and trends of the abdominal aortic aneurysms epidemic in general population - a meta-analysis. PLoS One 2013; 8(12): e81260.

Summers

Kerut

Sheahan

, et al. Evaluating the prevalence of abdominal aortic aneurysms in the United States through a national screening database. J Vasc Surg 2021; 73(1): 61–68.

Yei

Mathlouthi

Naazie

, et al. Long-term outcomes associated with open vs endovascular abdominal aortic aneurysm repair in a medicare-matched database. JAMA Netw Open 2022; 5(5): e2212081.

Kuivaniemi

Ryer

Elmore

, et al. Understanding the pathogenesis of abdominal aortic aneurysms. Expert Rev Cardiovasc Ther 2015; 13(9): 975–987.

Eagleton

. Inflammation in abdominal aortic aneurysms: cellular infiltrate and cytokine profiles. Vascular 2012; 20(5): 278–283.

Lindholt

Shi

. Chronic inflammation, immune response, and infection in abdominal aortic aneurysms. Eur J Vasc Endovasc Surg 2006; 31(5): 453–463.

Yuan

Wei

, et al. Abdominal aortic aneurysm: roles of inflammatory cells. Front Immunol. 2020; 11: 609161.

GBD 2021 Anaemia Collaborators . Prevalence, years lived with disability, and trends in anaemia burden by severity and cause, 1990-2021: findings from the Global Burden of Disease Study 2021. Lancet Haematol 2023; 10(9): e713–e734.

Diehm

Benenati

Becker

, et al. Anemia is associated with abdominal aortic aneurysm (AAA) size and decreased long-term survival after endovascular AAA repair. J Vasc Surg 2007; 46(4): 676–681.

10.

Stauder

Thein

. Anemia in the elderly: clinical implications and new therapeutic concepts. Haematologica 2014; 99(7): 1127–1130.

11.

Joosten

Lioen

. Iron deficiency anemia and anemia of chronic disease in geriatric hospitalized patients: how frequent are comorbidities as an additional explanation for the anemia? Geriatr Gerontol Int 2015; 15(8): 931–935.

12.

Howard

DPJ

Banerjee

Fairhead

Oxford Vascular Study , et al. Population-based study of incidence of acute abdominal aortic aneurysms with projected impact of screening strategy. J Am Heart Assoc 2015; 4(8): e001926.

13.

Newman

Jean-Claude

, et al. Cytokines that activate proteolysis are increased in abdominal aortic aneurysms. Circulation 1994; 90(5 Pt 2): II224–II227.

14.

Shteinberg

Halak

Shapiro

, et al. Abdominal aortic aneurysm and aortic occlusive disease: a comparison of risk factors and inflammatory response. Eur J Vasc Endovasc Surg 2000; 20(5): 462–465.

15.

Gupta

Sundaram

Mactaggart

, et al. Preoperative anemia is an independent predictor of postoperative mortality and adverse cardiac events in elderly patients undergoing elective vascular operations. Ann Surg 2013; 258(6): 1096–1102.

16.

Dakour-Aridi

Nejim

Locham

, et al. Anemia and postoperative outcomes after open and endovascular repair of intact abdominal aortic aneurysms. J Vasc Surg 2019; 69(3): 738–751.

17.

Organization

. Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity. Concentrations en hémoglobine permettant de diagnostiquer l’anémie et d’en évaluer la sévérité [Internet]. Organisation mondiale de la Santé, WHO/NMH/NHD/MNM/11.1, 2011. https://iris.who.int/handle/10665/85839.

18.

Ganz

. Molecular control of iron transport. J Am Soc Nephrol 2007; 18(2): 394–400.

19.

Weiss

. Pathogenesis and treatment of anaemia of chronic disease. Blood Rev 2002; 16(2): 87–96.

20.

Konijn

Carmel

Levy

, et al. Ferritin synthesis in inflammation. II. Mechanism of increased ferritin synthesis. Br J Haematol 1981; 49(3): 361–370.

21.

Nissenson

Goodnough

Dubois

. Anemia: not just an innocent bystander? Arch Intern Med 2003; 163(12): 1400–1404.

22.

Faria

Mejia

Miana

, et al.

Anemia in cardiac surgery - can something bad get worse?

Braz J Cardiovasc Surg 2021; 36(2): 165–171.

23.

Gaba

Serruys

Sabik

, et al. Effect of baseline anemia on outcomes after left main coronary revascularization. J Am Coll Cardiol 2020; 75(12): 1493–1495.

24.

Kulier

Levin

Moser

Investigators of the Multicenter Study of Perioperative Ischemia Research Group and Ischemia Research and Education Foundation , et al. Impact of preoperative anemia on outcome in patients undergoing coronary artery bypass graft surgery. Circulation 2007; 116(5): 471–479.

25.

Deng

Weng

Zhang

. Preoperative anemia and long-term survival in patients undergoing colorectal cancer surgery: a retrospective cohort study. World J Surg Oncol 2023; 21(1): 122.

26.

Quinn

Meland

McGinn

, et al. Correction of iron-deficiency anaemia in colorectal surgery reduces perioperative transfusion rates: a before and after study. Int J Surg 2017; 38: 1–8.

27.

Hernandez-Morgan

Neelankavil

Grogan

, et al. Preoperative anemia as a risk factor for postoperative outcomes in patients undergoing lung transplantation. J Cardiothorac Vasc Anesth 2021; 35(8): 2311–2318.

28.

Pothof

Bodewes

TCF

O’Donnell

TFX

, et al. Preoperative anemia is associated with mortality after carotid endarterectomy in symptomatic patients. J Vasc Surg 2018; 67(1): 183–190.

29.

Bodewes

TCF

Pothof

Darling

, et al. Preoperative anemia associated with adverse outcomes after infrainguinal bypass surgery in patients with chronic limb-threatening ischemia. J Vasc Surg 2017; 66(6): 1775–1785.

30.

Duarte

Catanoce

Zabeu

, et al. Association of preoperative anemia and increased risk of blood transfusion and length of hospital stay in adults undergoing hip and knee arthroplasty: an observational study in a single tertiary center. Health Sci Rep 2021; 4(4): e448.

31.

Manrai

Dawra

Kapoor

, et al. Anemia in cirrhosis: an underestimated entity. World J Clin Cases 2022; 10(3): 777–789.

32.

Weiss

. Anemia of chronic disorders: new diagnostic tools and new treatment strategies. Semin Hematol 2015; 52(4): 313–320.

33.

Nemeth

. Anti-hepcidin therapy for iron-restricted anemias. Blood 2013; 122(17): 2929–2931.

34.

Kidanewold

Woldu

Enawgaw

. Role of erythropoiesis stimulating agents in the treatment of anemia: a literature review. Clin Lab 2021; 67(4).

35.

Sidawy

Nguyen

. Comparative assessment of racial disparity in 30-day outcomes for Asian Americans undergoing carotid endarterectomy. J Vasc Surg 2024; 79(5): 1132–1141. https://www.jvascsurg.org/article/S0741-5214(23)02439-4/abstract