The effect of thoracoabdominal aneurysm repair on quality of life
Article Outline
Objective
The objective of this study is to assess the impact of surgery on quality of life (QOL) in patients who underwent thoracoabdominal aortic aneurysm (TAAA) repair.
Methods
This is a prospective single center cohort study using two quality of life questionnaires administered before surgery, at 6 months, and 1 year after surgery. The Illness Intrusiveness Rating Scale (IIRS) is a tool that on a 7-point Likert scale assesses the impact of disease on each of 13 domains of quality of life. The Karnofsky Activity Scale (KAS) uses a single rating to assess the impact on overall quality of life. At each visit, participants completed the IIRS and KAS. Healthy, nonaneurysmal individuals also completed the IIRS to form a control group.
Results
From 1998 to 2006, 297 patients underwent thoracoabdominal aneurysm repair at a tertiary care hospital. Quality of life was measured on 80 patients in total. Preoperative data was available in 45 patients (7 completed the IIRS and 3 the KAS only, and 35 both); 6-month postoperative data in 25 (1 completed the KAS only, and 24 both); and 1-year data postoperative in 35 (4 completed the IIRS and 2 the KAS only, and 29 both). Internal consistency was established for IIRS (Cronbach's alpha 0.85) and KAS (0.81). The mean preoperative IIRS score was 32.10 (SD 17.91). After surgery, there was no change at the 6-month and 1-year postoperative intervals: at 6 months, the mean IIRS score was 33.17 (SD 17.66) and at 1 year the mean was 28.09 (SD 13.61). Total IIRS in nonaneurysmal controls was 13.5 (SD 0.7). The mean preoperative Karnofsky Activity Scale score was 80.0 (SD 15.07), which corresponds to an ability to perform normal activity with effort and some signs or symptoms of disease. After surgery, there was no change as patients reported a 6-month mean score of 79.60 (SD 21.89), and a 1-year postoperative mean score of 86.94 (SD 13.94).
Conclusions
Quality of life for patients undergoing TAAA repair who survive to attend follow-up in an ambulatory setting can be measured using reliable and valid instruments. Preoperatively, QOL is poor compared with healthy controls. After surgery, at 6- and 12-month follow-up, QOL seems to return to the preoperative levels. Further research is necessary to address responsiveness and sensitivity of QOL measuring tools.
In population-based studies, the prevalence of thoracoabdominal aortic aneurysms (TAAA)1 and thoracic aortic aneurysms2 is 5.9 and 10.4 per 100,000 person years in the white population. This prevalence increases with age and is greater in men than in women. The largest single-center series indicates that surgery for TAAA represents 10% of all surgeries for aneurysms of the aorta.3
The rationale for surgical intervention in thoracoabdominal aneurysms is the prevention of spontaneous rupture and death. Without treatment, the risk of rupture and 5-year survival in thoracic aortic aneurysms (aneurysm greater than 5 cm or twice the size of the normal proximal or distal aorta) is estimated to be 47% to 74% and 21% (95% CI 15-32), respectively, in cohort studies from tertiary care centers.1, 4 Other cohort studies of thoracoabdominal aortic aneurysms have documented a 5-year survival rate of 39% (95% CI 46% to 73%) and 4-year risk of rupture of 32% (95% CI 11% to 41%).5 Crawford evaluated 94 patients who did not undergo thoracoabdominal aortic aneurysm repair either because of associated disease, age, small size of aneurysm, procedure refusal, and found by Kaplan-Meyer curve analysis that the 2-year survival rate was only 24%.6 Half of the deaths in this series were due to rupture.
The incidence of postoperative complications after TAAA repair is high, including up to 32% incidence of respiratory insufficiency, 21% incidence of renal dysfunction, 14% incidence of paraplegia/paraparesis, and 12% incidence of pulmonary infection.7 Rupture is the first sign of the disease in 10% to 20% of patients.8 TAAAs are largely asymptomatic, however, a greater number of patients than in the past are aware of this medical condition as a consequence of ageing and increased ascertainment. We hypothesize that these patients who are made aware of their condition may experience increased fear and anxiety, which worsens quality of life, and that the latter may be worsened in those patients in whom surgery is performed.
We believed that an instrument to describe the burden of illness and to quantify the effect of the interventions on quality of life is needed in order to help physicians and patients to communicate realistically on surgical outcomes.
The primary objective of this study is to assess the effect of thoracoabdominal aortic aneurysms and surgery on the quality of life of these patients.
Material and methods
Participants
This is a prospective cohort study of elective patients with TAAA being considered for surgical intervention by a single surgeon at a tertiary care center between 1998 and 2006. All patients were enrolled before endovascular repair of TAAA was made available in a routine fashion at our institution.
Participants in the quality of life study (study group) were compared with all other patients undergoing a TAAA repair who did not participate in the study (TAAA control group). In addition, participants randomly selected from among office assistants, and individuals from physicians' offices older than 15 years of age and who were not affected by aneurysmal disease provided a nonaneurysmal control group. The study received institutional ethic review board approval.
Instrument
In this study population, two quality of life instruments were used, in order to strengthen their validity (convergent validity). The first is the Illness Intrusiveness Rating Scale (IIRS), which uses a 7-point Likert scale to assess the impact of disease on each of 13 domains of quality of life: health, diet, work, active and passive recreation, financial situation, relationship with spouse/significant other, sex life, family and other social relations, self expression/self improvement, religious expression, and community/civic involvement. For each domain of the IIRS, a response of 7 represents “most intrusive” or “more severe” problems while a response of 1 represents “minimal” or “no problems”. Scores on this scale decrease with improvement in quality of life.
We chose to investigate the properties of the Illness Intrusiveness Ratings Scale (IIRS) because the concept of intrusiveness seemed to capture the condition's disruptive effects on many aspects of life described by patients. Previous research has supported the construct validity of the scale. The IIRS has been shown to have internal consistency (Cronbach's alpha of 0.80 to 0.88)9, 10, 11 and test-retest reliability (K of 0.79 to 0.85)10, 12, 13, 14, 15 in assessing quality of life in chronic and life threatening conditions. It is a short, self-administered scale of 13 items. The brevity of the scale is an important factor considering the applicability of the instrument to clinical practice.
The second instrument is the Karnofsky Activity Scale (KAS), which uses a single rating from 0-100 to assess the impact on overall quality of life, ranging from “0: dead” to “100: normal, no complaints, no evidence of distress”. Scores increase with improvements in quality of life. The Karnofsky Activity Scale has been used to assess the severity of impact of abdominal aortic aneurysms on quality of life.16 It has additionally been shown to be reliable and valid in cancer patients, with inter-rater reliability (K = .97) and validity (r = 0.30).17 Its validity and reliability as a universal indicator of quality of life has been demonstrated in previous research.18, 19, 20
We believed that the use of a generic instrument (KAS) in combination with one that is disease-specific (IIRS) may provide the most comprehensive data.21
All patients completed the self-administered questionnaire before surgery, and at two routine postoperative follow-up periods at 6-month and 1-year. For the purposes of this study, if participants completed more than one scale following the 1-year interval, the score with the earliest date was selected in order to provide comparable results to those patients whose follow-up was shorter. Patients requiring urgent or emergent TAAA repair were excluded from analysis. In a subset of 10 patients, the quality of life scale was administered twice before surgery at a 4-week interval. In addition, the IIRS was administered to the nonaneurysmal control group.
Surgical technique
We have previously described our center's approach to open thoracoabdominal aneurysm repair in detail, which included a protocol-based strategy. Mortality and morbidity of the surgery have been reported elsewhere.22, 23, 24, 25
Statistical analysis
All data was tabulated in an electronic database using Microsoft Access. Statistical analysis was undertaken using SPSS (Version 12). Fisher exact test was used for categorical variables, and unpaired two-tailed t test for continuous. We used analysis of variance for continuous variables to compare changes in pre- and postoperative scores. A P value <.05 was considered significant. Cronbach's alpha was calculated to test the internal consistency. Analysis of variance components and intraclass correlation (ICC) were used to calculate test-retest reliability.
Results
From 1998 to 2006, there were 297 TAAA repairs performed at our tertiary care center, and pre- and postoperative QOL assessment was performed on 80 patients (study group) who were administered both scales. None of the patients participating in this study suffered paraplegia or had renal failure requiring permanent dialysis. Preoperatively, 35 patients completed both the IIRS and the KAS and seven patients only the IIRS and three only the KAS; at 6 months 24 completed both scales and one only the KAS; at 1 year 29 completed both scales, four only the IIRS and two only the KAS (Fig 1). The total IIRS score for the healthy, nonaneurysmal control group was 13.5 ± 0.7, which was significantly different from that observed in patients with TAAA at any time point, before or after surgery (Table I). Quality of life data on the KAS scale was available for 38 patients before surgery, 25 at 6 months and 32 at 1 year after surgery. Demographic variables associated with surgical outcome for participants in the study and in the TAAA control group are described in Table II. The study group was younger (P = .03), had a greater number of more complex group II TAAA and had a higher serum albumin level (P = .001). There appears to be fewer urgent cases in the study group and better renal function, but this difference did not achieve statistical significance (P = .08). In-hospital mortality occurred in five patients who completed QOL scales, or 6.2% compared with 14.1% of patients in the cohort (P = .08).
Fig.
Flow chart of participants.
Table I. IIRS scores for the healthy, nonaneurysmal control group
| Controls (N =11) mean ± SD | |
|---|---|
| Health | 1 ±0 |
| Diet | 1.1±0.2 |
| Work | 1.1±0.2 |
| Active recreation | 1.3±0.5 |
| Passive recreation | 1±0 |
| Financial situation | 1±0 |
| Relationship: spouse | 1±0 |
| Sex life | 1±0 |
| Family relations | 1±0 |
| Social relations | 1±0 |
| Self expression | 1±0 |
| Religious expression | 1±0 |
| Community | 1±0 |
| Total IIRS score | 13.5±0.7 |
Table II. Demographics in participants for the study group and TAAA control
| Study group | TAAA control group | P | |
|---|---|---|---|
| N | 80 | 219 | |
| Male sex (%) | 66 | 58.9 | .73 |
| Age, mean (SD) | 66.2(11.0) | 69.3(10.7) | .03 |
| Aneurysm size in cm, mean (SD) | 6.42(1.2) | 6.59(1.5) | .37 |
| TAAA type, number (%) | |||
| Ia | 6(8) | 8(4.3) | .21 |
| Ib | 7(9) | 22(11.8) | .83 |
| II | 28(35) | 36(19.3) | .001 |
| III | 7(10.1) | 34(18.3) | .13 |
| IV | 21(26) | 83(44.62) | .06 |
| V | 0(0.0) | 3(1.61) | .57 |
| Type of surgery, number % | |||
| Urgent | 1(1.3) | 15(6.8) | .08 |
| Emergency | 1(1.3) | 6(2.7) | .70 |
| FEV1, L , mean(SD) | 2.3(0.8) | 2.2(0.6) | .25 |
| FEV1/FVC, % predicted, mean (SD) | 61.7(21.4) | 70.2(18.7) | .001 |
| Grade 1 ventricle (%) | 100 | 100 | 1.00 |
| Serum creatinine, μmol/L | 113.7(55.8) | 128.2(65.7) | .08 |
| Serum albumin, g/L | 41.5(4.7) | 35.7(7.1) | .0001 |
| Smokers (past or present), % | 66 | 53.4 | .08 |
Internal consistency of the IIRS and the KAS was high, Cronbach's alpha 0.85 and 0.81, respectively. Test-retest reliability was also high, ICC coefficient 0.89. Mean KAS and IIRS scores for each time interval are reported in Table III and the results of the individual items for the IIRS are reported in Table IV. There was not a statistical difference in the total score of the IIRS before and after surgery at 6 and 12 months. The results of the QOL as measured by the KAS appeared to improve over time, but the difference did not achieve statistical significance (P = .07).
Table III. KAS and IIRS scores for each time interval
| Preoperative mean | Postoperative mean | P | ||
|---|---|---|---|---|
| 6 mo | P 12 mo | |||
| IIRS score, mean (SD) | (N=42)32.10(17.91) | (N=24)33.17(17.66) | (N=33)28.09(13.61) | .13 |
| KAS score, mean (SD) | (N=38)80.00(15.07) | (N=25)79.60(21.89) | (N=31)86.94(13.94) | .07 |
Table IV. Categorical IIRS scores for each time interval
| No | Preoperative mean (SD) | Postoperative mean (SD) | P | ||
|---|---|---|---|---|---|
| 6 mo | 12 mo | ||||
| Health | 62 | 3.40(2.53) | 3.66(2.18) | 3.09(1.98) | .42 |
| Diet | 63 | 2.64(2.14) | 2.46(2.17) | 1.51(1.09) | .07 |
| Work | 63 | 2.98(2.47) | 2.88(2.58) | 1.97(1.69) | .06 |
| Active recreation | 63 | 3.77(2.61) | 4.00(2.52) | 3.20(2.17) | .17 |
| Passive Recreation | 63 | 1.66(1.54) | 1.75(1.54) | 1.74(1.58) | .94 |
| Financial Situation | 63 | 2.23(1.94) | 2.58(2.48) | 2.06(1.78) | .36 |
| Relationship: Spouse | 62 | 2.40(2.19) | 2.29(1.85) | 1.88(1.75) | .29 |
| Sex life | 62 | 3.00(2.61) | 2.71(2.51) | 2.44(2.27) | .45 |
| Family relations | 63 | 2.05(1.87) | 1.83(1.58) | 1.64(1.56) | .39 |
| Social relations | 63 | 2.31(1.84) | 2.58(2.08) | 2.15(1.82) | .45 |
| Self expression | 62 | 2.51(1.97) | 2.75(1.98) | 2.55(2.17) | .78 |
| Religious Expression | 61 | 1.43(1.09) | 1.58(1.06) | 1.64(1.60) | .65 |
| Community | 61 | 2.14(1.89) | 2.08(2.06) | 2.42(2.29) | .63 |
Discussion
We use the IIRS and the KAS to provide a composite global assessment of quality of life because previous authors have demonstrated that the IIRS is reliable and valid for chronic and life threatening conditions and KAS16 has also been used to assess quality of life in aortic aneurysms.26 We have shown that participants with TAAA before surgery have low KAS scores (mean 80%), and that they have higher IIRS scores (mean 32) than healthy nonaneurysmal controls (mean of 13.5), and more in keeping with the results obtained in transplant patients (bone marrow [37.5, 95% CI, 32.3-42.8], lung [30.4, 95% CI, 25.8-35.1] and liver transplants [32.2, 95% CI, 29.2-35.3]) or in patients with severe chronic conditions such rheumatoid arthritis (38, 95% CI, 34-44).14, 27
It is difficult to explain how a seemingly asymptomatic condition affects quality of life in such a profound manner. Perhaps the associated comorbidities and the anxiety caused by hosting the disease may in part be responsible for these results. A study of 1509 patients with TAAA showed that comorbidities are prevalent in this population and include chronic lung disease in 40% (95% CI 37.5-42.4), atherosclerotic heart disease in 31% (95% CI 28.8-33.5), cerebrovascular disease in 15% (95% CI 13.4-17.1), and renal insufficiency in 13% (95% CI 12.2-15.7).3 All of these may profoundly affect quality of life.
Olsson et al, using eight dimensions of the SF-36 showed that (except for bodily pain) the quality-of-life after thoracic aortic surgery was acceptable, although worse than in the normal population.28 Eide et al, using a short form of the SF-36 showed that in thoracoabdominal aortic aneurysm surgery, most patients reported an acceptable health related quality of life.28, 29 In our work, though the results of quality of life measures at 6 and 12 months were unchanged compared with those recorded preoperatively, they were still indicative of significant impairment. This suggests that after appropriate recovery, the quality of life of these patients returns to their preoperative status. We cannot, however, exclude with certainty that deterioration does not occur. A ceiling effect and unresponsiveness of the measuring scale to change might be responsible for our findings.30
Zierer et al have shown that QOL in patients undergoing TAAA repair is worse than that in those undergoing ascending or descending aneurysms repair, and that this effect is independent of age.31 Long-term quality of life at 5 years of patients receiving thoracic aortic aneurysm repair seems to be reduced compared with controls.32 Endovascular aortic aneurysms repair (EVAR) offers promises of reducing mortality and improving quality of life. Interestingly, in Dick's study, patients undergoing thoracic endovascular aneurysms repair (TEVAR) did not score higher in overall quality of life compared with those who received open surgery despite all advantages of minimized access trauma.32 Similarly, anxiety and depression scores were not reduced by TEVAR, possibly reflecting a certain caution against the new technology.
The strength of our work is based on the use of two different scales to assess quality of life, the simplicity with which these scales may be used in clinical practice to aid in decision making regarding indications for surgery, the large sample size, and length of follow-up.
We suggest that the results obtained in the cohort of patients in whom quality of life was studied are generalizable to the entire cohort of patients undergoing TAAA repair. Although there is likely an intrinsic selection bias (eg, differences in serum albumin and age were identified between the study group and TAAA control group), which interferes with the interpretation of QOL studies, an association with the relationship between questionnaire participation and outcomes cannot be ruled out. If this is indeed a real effect, then it would certainly be a problem that may be generalized to all studies using QOL as an outcome. This might lead to discussing the appropriateness of insurers trying to add QOL criteria to pay-for-performance and ratings outcomes for operations such as these. In our study, the responders to the QOL questionnaires appeared younger that the TAAA control group. However, a study of thoracic aortic aneurysms concluded that while the impact on physical aspect of quality of life is greatest with TAAA repair, advanced age is not predictive of impaired recovery compared to younger patients.31
The inference that may be drawn by our work is further limited by lack of randomization and selection bias; the propensity for patients to exaggerate the severity of their condition to be eligible for surgery and underplay symptoms following intervention; recall bias as responses to the questionnaires may be affected by the patients' memories.
Conclusions
Surgical repair is an effective treatment for TAAA with acceptable results in tertiary centres with expertise in the management of this condition. The quality of life as assessed by the IIRS and KAS scales is poor before surgery, but seems to return to the preoperative status after 6 to 12 months recovery. Further studies addressing responsiveness to change of QOL measuring scales and their sensitivity in this patient population are necessary to better define the impact on quality of life of patients undergoing TAAA repair.
Author contributions
References
- Thoracic aortic aneurysms: a population-based study. Surgery. 1982;92:1103–1108
- . Improved prognosis of thoracic aortic aneurysms: a population-based study. J Am Med Assoc. 1998;280:1926–1929
- . Experience with 1509 patients undergoing thoracoabdominal aortic operations. J Vasc Surg. 1993;17:357–368
- . Thoracic aortic aneurysm: natural history and treatment. J Thorac Cardiovasc Surg. 1980;79:489–498
- Outcome and expansion rate of 57 thoracoabdominal aortic aneurysms managed nonoperatively. Am J Surg. 1995;170:213–217
- . Thoracoabdominal aortic aneurysm: observations regarding the natural course of the disease. J Vasc Surg. 1986;3:578–582
- . Nondissecting thoracoabdominal aortic aneurysms: part I. Ann Vasc Surg. 1995;9:503–514
- . Thoracoabdominal aortic aneurysms. In: Rutherford R editors. Vascular surgery. Philadelphia: Saunders; 2005;p. 1490–1511
- . Long-term results of 630 thoracoscopic sympathectomies for primary hyperhidrosis: the Vienna experience. Eur J Surg Suppl. 1998;(580):43–46
- Long-term results of endoscopic thoracic sympathectomy for upper limb hyperhidrosis. Ann Thorac Surg. 2003;75:1075–1079
- . Uniportal endoscopic thoracic sympathectomy for treatment of palmar and axillary hyperhidrosis: analysis of 2000 cases. Neurosurgery. 2002;51:S84–S87
- . Quality of life after transthoracic endoscopic sympathectomy for upper limb hyperhidrosis. Eur J Surg Suppl. 1998;(580):39–42
- . The Illness Intrusiveness Rating Scale: a measure of severity in individuals with hyperhidrosis. Quality Life Res. 1999;8:693–698
- . Illness intrusiveness in rheumatoid arthritis: differential impact on depressive symptoms over the adult lifespan. J Rheumatol. 1992;19:709–715
- . Differences in illness intrusiveness across rheumatoid arthritis, end-stage renal disease, and multiple sclerosis. J Nerv Ment Dis. 1993;181:337–381
- Pain and quality of life assessment after endovascular versus open repair of abdominal aortic aneurysms in patients at low risk. J Vasc Intervent Radiol. 2005;16:1093–1100
- . The Karnofsky Performance Status Scale (An examination of its reliability and validity in a research setting). Cancer. 1984;53:2002–2007
- . The Karnofsky Performance Status Scale re-examined: a cross-validation with the EORTC-C30. Quality Life Res. 1994;3:413–424
- . Validity of the Karnofsky Performance Status in an HIV-infected sample. J Acquir Immun Defic Syndr Hum Retrovirol. 1995;10:350–357
- . Evaluation of patients with advanced cancer using the Karnofsky performance status. Cancer. 1980;45:2220–2224
- . Quality of life after esophageal surgery. Thorac Surg Clin. 2004;14:367–374
- Thoracoabdominal aortic aneurysm repair: a prospective cohort study of 121 cases. Ann Vasc Surg. 2002;16:631–638
- . Acute normovolemic hemodilution (ANH) in surgery of the thoraco-abdominal aorta (A cohort study to evaluate coagulation parameters and blood products utilization). J Cardiovasc Surg. 1999;40:37–43
- . A cohort study of coagulation parameters and the use of blood products in surgery of the thoracic and thoracoabdominal aorta. J Vasc Surg. 2001;33:462–468
- . A modified technique of atriofemoral bypass for visceral and distal aortic perfusion in thoracoabdominal aortic surgery. Ann Vasc Surg. 1999;13:560–565
- . Illness intrusiveness and the psychosocial impact of lifestyle disruptions in chronic life-threatening disease. Adv Renal Replace Ther. 1994;1:251–263
- Illness intrusiveness among survivors of autologous blood and marrow transplantation. Cancer. 2001;92:3147–3154
- . Quality of life in survivors of thoracic aortic surgery. Ann Thorac Surg. 1999;67:1262–1267
- . Health-related quality of life in long term-survivors of thoracoabdominal aortic aneurysm repair. J Vasc Nurs. 2005;23:88–94
- . Type I error inflation in the presence of a ceiling effect. Am Statist. 2003;57:97–104
- . Elective surgery for thoracic aortic aneurysms: late functional status and quality of life. Ann Thorac Surg. 2006;82:573–578
- Outcome and quality of life after surgical and endovascular treatment of descending aortic lesions. Ann Thorac Surg. 2008;85:1605–1612
Competition of interest: Dr Cinà has been paid a consulting fee by Vascutek and Cook Companies and is on their speakers bureau.
PII: S0741-5214(09)00008-1
doi:10.1016/j.jvs.2009.01.006
© 2009 Published by Elsevier Inc.
