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Long-Term Outcomes of Abdominal Aortic Aneurysm
Study Questions:
What are the long-term (up to 8 years) outcomes of endovascular repair versus open repair for abdominal aortic aneurysms?
Methods:
The investigators assessed perioperative and long-term survival, reinterventions, and complications after endovascular repair as compared with open repair of abdominal aortic aneurysm in propensity-score–matched cohorts of Medicare beneficiaries who underwent repair during the period from 2001 through 2008 and were followed through 2009. Rates of survival, freedom from rupture, and reintervention related to abdominal aortic aneurysm were estimated with the use of Kaplan–Meier life-table methods, and comparisons were made with the use of a log-rank analysis.
Results:
The investigators identified 39,966 matched pairs of patients who had undergone either open repair or endovascular repair. The overall perioperative mortality was 1.6% with endovascular repair versus 5.2% with open repair (p < 0.001). From 2001 through 2008, perioperative mortality decreased by 0.8 percentage points among patients who underwent endovascular repair (p = 0.001) and by 0.6 percentage points among patients who underwent open repair (p = 0.01). The rate of conversion from endovascular to open repair decreased from 2.2% in 2001 to 0.3% in 2008 (p < 0.001). The rate of survival was significantly higher after endovascular repair than after open repair through the first 3 years of follow-up, after which time the rates of survival were similar. Through 8 years of follow-up, interventions related to the management of the aneurysm or its complications were more common after endovascular repair, whereas interventions for complications related to laparotomy were more common after open repair. Aneurysm rupture occurred in 5.4% of patients after endovascular repair versus 1.4% of patients after open repair through 8 years of follow-up (p < 0.001). The rate of total reinterventions at 2 years after endovascular repair decreased over time (from 10.4% among patients who underwent procedures in 2001 to 9.1% among patients who underwent procedures in 2007).
Conclusions:
The authors concluded that endovascular repair, as compared with open repair, of abdominal aortic aneurysm was associated with a substantial early survival advantage that gradually decreased over time.
Perspective:
This study reports that the early survival benefit with endovascular repair as compared with open repair persisted for almost 3 years, after which time the survival was similar in the two groups. The overall rate of late complications, including aneurysm-related interventions, procedures for complications related to laparotomy, and admissions for bowel obstruction, was slightly lower after open repair than after endovascular repair, but the rates of adverse outcomes after endovascular repair, including perioperative mortality and rates of reintervention, decreased over time. However, late rupture after endovascular repair is a concern and occurred in 5.4% of patients through 8 years of follow-up. The choice of open versus endovascular repair for AAA should be individualized and based on risk–benefit analysis by a multidisciplinary team and patient preference.
Keywords: Aneurysm, Ruptured, Aneurysm, Aortic Aneurysm, Abdominal, Endovascular Procedures, Laparotomy, Medicare, Survival, Vascular Diseases
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