Preoperative Factors Affect Discharge Destination After Open Aortic Aneurysm Repair

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Preoperative counseling of patients with an intact abdominal aortic aneurysm (AAA) requires discussion of downstream consequences, especially when a patient is a candidate for either open or endovascular repair. One consideration is the patient's early postoperative functional status and their need for discharge to a rehabilitation facility versus direct discharge to home.

In a retrospective study published in the Journal of Surgical Research, Clinical Fellow in Vascular Surgery, Laura T. Boitano, MD, Assistant Program Director of the Division of Vascular and Endovascular Surgery, Mark F. Conrad, MD, MMSc, and colleagues determined that nonhome discharge following open aortic aneurysm repair (OAR) could be predicted using five preoperative factors:

1. Age
2. Functional status
3. Sex
4. History of bleeding disorder
5. Expectation of prolonged operative time (complex repair)

The researchers evaluated 510 patients in the Vascular Targeted Participant Use Data Files of the American College of Surgeons National Surgical Quality Improvement Program for home-dwelling patients who underwent emergent infrarenal OAR between 2011 and 2015. 17.1% of them required nonhome discharge (to a rehabilitation unit, separate acute care facility, skilled care facility or unskilled care facility).

Multivariable logistic regression analysis demonstrated that the strongest predictors of nonhome discharge were:

• Age ≥70 (OR, 12.48; 95% CI, 2.88–53.99; = .001)
• Partial dependence in activities of daily living at baseline (OR, 8.17; 95% CI, 1.39–47.83; = .02)

26% of patients age 70 and older required nonhome discharge, compared with 3% of those under 60. No patients were fully dependent in activities of daily living at baseline, and the researchers suspect that the population may be too frail for OAR.

Other independent predictors of nonhome discharge were:

• Female sex (OR, 1.88; 95% CI, 1.11–3.20; = .02)
• Preoperative bleeding disorder (OR, 2.65; 95% CI, 1.14–6.15; = .02)
• Operative time >5 hours (OR, 1.84; 95% CI, 1.03–3.26; = .04)

A number of theories have been advanced about why women tend to have poorer outcomes after AAA repair. Some of the hypotheses are that women have more challenging anatomy, are less likely to receive optimal treatment because of comorbidities or are more likely to have an older, sicker spouse incapable of caring for them.

Another possibility is that women are older at the time of OAR, which may contribute to nonhome discharge if they have outlived their spouse or partner. The current study supports that idea, as women's average age was 72, compared with 68.8 for men. However, female sex remained a significant predictor of nonhome discharge even after adjustment for age.

Surgeons often know preoperatively whether a case will be especially challenging. They used operative time as a proxy for that estimation. They recommend discussing case complexity during preoperative counseling to help patients set realistic expectations about postoperative outcomes.

Given the relatively few predictors of nonhome discharge, it is likely that a risk score could be developed to clinically predict the need for nonhome discharge after OAR. Research conducted to develop such a score should consider factors that were not available in the database used in this study:

• Socioeconomic status and social support
• Impaired sensorium
• History of hemi/paraplegia
• History of myocardial infarction
• Hospital practices
• Surgeon volume
• Surgeon experience

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