Long-term Outcomes Associated With Open vs Endovascular Abdominal Aortic Aneurysm Repair in a Medicare-Matched Database.

Journal: JAMA Network Open
Treatment Used: Open vs. Endovascular Abdominal Aortic Aneurysm Repair
Number of Patients: 32760
Published:
MediFind Summary

Summary: This review of literature evaluated the long-term outcomes associated with open (traditional type of surgery that involve the need to make larger incisions to perform the surgery because cameras are not used) versus endovascular (procedure that uses very small cuts and long, thin tubes called catheters, which are placed inside a blood vessel to repair it) abdominal aortic aneurysm (enlarged area in the lower part of the major vessel that supplies blood to the body) repair.

Conclusion: Overall mortality (death) after elective abdominal aortic aneurysm (enlarged area in the lower part of the major vessel that supplies blood to the body) repair was higher with endovascular (procedure that uses very small cuts and long, thin tubes called catheters, which are placed inside a blood vessel to repair it) repair than open (traditional type of surgery that involve the need to make larger incisions to perform the surgery because cameras are not used) repair despite reduced 30-day mortality and perioperative (during surgery) morbidity (state of disease) after endovascular repair. Endovascular repair was associated with significantly higher rates of long-term rupture and reintervention.

Abstract

Importance: Endovascular aneurysm repair is associated with a significant reduction in perioperative mortality and morbidity compared with open aneurysm repair in the treatment of abdominal aortic aneurysm. However, this benefit decreases over time owing to increased reinterventions and late aneurysm rupture after endovascular repair.

Objective: To compare long-term outcomes of endovascular vs open repair of abdominal aortic aneurysm. Design, setting, and participants: This multicenter retrospective cohort study used deidentified data with 6-year follow-up from the Medicare-matched Vascular Quality Initiative Vascular Implant Surveillance and Interventional Outcomes Network database. Patients undergoing first-time elective endovascular or open abdominal aortic aneurysm repair from 2003 to 2018 were propensity score matched. Patients with ruptured abdominal aortic aneurysm, concomitant procedures, or prior history of abdominal aortic aneurysm repair, were excluded. Data were analyzed from January 1, 2003, to December 31, 2018. Exposures: First-time elective endovascular or open repair for abdominal aortic aneurysm. Main outcomes and measures: The primary long-term outcome of interest was 6-year all-cause mortality, rupture, and reintervention. Secondary outcomes included 30-day mortality and perioperative complications.

Results: Among a total of 32 760 patients (median [IQR] age, 75 [70-80] years; 25 706 [78.5%] men) who underwent surgical abdominal aortic aneurysm repair, 28 281 patients underwent endovascular repair and 4479 patients underwent open repair. After propensity score matching, there were 2852 patients in each group. Open repair was associated with significantly lower 6-year mortality compared with endovascular repair (548 deaths [35.6%] vs 608 deaths [41.2%]; hazard ratio [HR], 0.83; 95% CI, 0.74-0.94; P = .002), with increases in mortality starting from 1 to 2 years (84 deaths [4.3%] vs 126 deaths [6.7%]; HR, 0.63; 95% CI, 0.48-0.83; P = .001) and 2 to 6 years (211 deaths [25.8%] vs 241 deaths [30.6%]; HR, 0.73; 95% CI, 0.61-0.88; P = .001). Open repair, compared with endovascular repair, also was associated with significantly lower rates of 6-year rupture (117 participants [5.8%] vs 149 participants [8.3%]; HR, 0.76; 95% CI, 0.60-0.97; P < .001) and reintervention (190 participants [11.6%] vs 267 participants [16.0%]; HR, 0.67; 95% CI, 0.55-0.80; P < .001). Open repair was associated with significantly higher odds of 30-day mortality (OR, 3.56; 95% CI, 2.41-5.26; P < .001) and complications. Conclusions and relevance: These findings suggest that overall mortality after elective abdominal aortic aneurysm repair was higher with endovascular repair than open repair despite reduced 30-day mortality and perioperative morbidity after endovascular repair. Endovascular repair additionally was associated with significantly higher rates of long-term rupture and reintervention. These findings emphasize the importance of careful patient selection and long-term follow-up surveillance for patients who undergo endovascular repair.

Authors
Kevin Yei, Asma Mathlouthi, Isaac Naazie, Nadin Elsayed, Bryan Clary, Mahmoud Malas

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