Thirty-Day Mortality and Late Survival With Reinterventions and Readmissions After Open and Endovascular Aortic Aneurysm Repair in Medicare Beneficiaries

Study Questions:

What is the effect of reintervention and readmission on long-term survival following open and endovascular abdominal aortic aneurysm (AAA) repair?

Methods:

A total of 45,652 Medicare beneficiaries were identified as having undergone open or endovascular (EVAR) AAA repair from 2001 to 2004. After propensity score matching to control for nonrandom treatment assignment, two groups of 22,826 patients each were studied. AAA-related, laparotomy-related, and reinterventions for both the open and EVAR groups were identified through 6 years of follow-up. Event rates and 30-day mortality were determined for each reintervention or readmission.

Results:

Overall, reintervention and readmission rates were similar between repair methods, but slightly more common after EVAR (7.6 vs. 7/100 person-years, p < 0.001). Thirty-day mortality rates with any intervention were 9.1%. Rupture was more common in EVAR patients (relative risk [RR], 5.7) and EVAR patients had more aneurysm-related reinterventions during the study period (RR, 4), which were mainly minor catheter-related procedures. Mortality was noted to be 5.6% and 3%, respectively. Minor open procedures (RR, 1.4) and major reinterventions (RR, 2.4) were more common in open AAA patients with a 30-day mortality of 6.9% and 12.1%, respectively. EVAR patients had fewer laparotomy-associated complications than open AAA patients (RR, 0.5), as well as fewer readmissions without surgery (RR, 0.7). Associated mortality was 8.1% and 10.9%, respectively for these. Reintervention and readmissions accounted for 9.6% of all EVAR and 7.6% of all open AAA patient deaths in the study (p < 0.001).

Conclusions:

Reintervention and readmission after open or endovascular AAA repair is associated with decreased late survival. EVAR is associated with higher reintervention and readmission rates, and this may partially account for loss of the survival advantage seen in the early postoperative period following EVAR repair.

Perspective:

Following initial endovascular repair, EVAR has been associated with increased late reintervention rates 3 times greater (approximately 15%) than open repair. Despite the usual limitations associated with analysis of administrative databases, the authors make a convincing argument that these increased reintervention and readmission rates negatively affect long-term survival after EVAR. In fact, the data suggest that the initial survival advantage conferred by EVAR can potentially be negated by the need for, and mortality associated with, secondary interventions. I agree with the authors that the next step should be an attempt to identify predictors of reintervention and readmission for both EVAR and open surgery in order to better guide decision-making in the treatment of patients with AAAs.

Clinical Topics: Invasive Cardiovascular Angiography and Intervention, Vascular Medicine, Interventions and Vascular Medicine

Keywords: Risk, Endovascular Procedures, Follow-Up Studies, Laparotomy, Aortic Aneurysm, Abdominal, Vascular Surgical Procedures, United States


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