Endovascular vs. Open Abdominal Aortic Aneurysm Repair

Study Questions:

What are the long-term outcomes associated with endovascular aneurysm repair (EVAR) versus open surgical repair for abdominal aortic aneurysm (AAA)?

Methods:

Using data from the EVAR randomized controlled trial (EVAR trial 1 [UK Endovascular Aneurysm Repair trial 1]), which enrolled 1,252 patients between September 1999 and August 2004, patients aged ≥60 years and with AAA ≥5.5 cm in diameter were randomized to EVAR or open surgical repair in a nonblinded fashion. The primary outcome was total and aneurysm-related deaths in each group through mid 2015 from the intention-to-treat population.

Results:

Over a mean of 12.7 years (standard deviation 1.5 years) of follow-up, mortality rates were 9.3/100 patient-years in the EVAR group and 8.9/100 patient-years in the open surgical repair group (adjusted hazard ratio [aHR], 1.11; 95% confidence interval [CI], 0.97-1.27; p = 0.14). At 0-6 months, patients randomized to EVAR had lower aneurysm-related mortality (aHR, 0.47; 95% CI, 0.23-0.93; p = 0.031) than open surgical repair. However, beyond 8 years of follow-up, EVAR had a higher total mortality (aHR, 1.25; 95% CI, 1.00-1.56; p = 0.48) and aneurysm-related mortality (aHR, 5.82; 95% CI, 1.64-20.65; p = 0.0064) as compared with open surgical repair. The increased aneurysm-related mortality in the EVAR group beyond 8 years is primarily attributed to secondary aneurysm sac rupture (13 [7%] vs. 2 [1%] deaths in EVAR and open surgical repair groups, respectively).

Conclusions:

The authors concluded that while EVAR has early survival benefit, open surgical repair has improved long-term survival for patients with AAA.

Perspective:

For patients with AAA, EVAR has become first-line therapy for most patients. This report of long-term mortality from the EVAR trial 1 study raises the important issue of continued surveillance for EVAR patients given the associated risk of secondary aneurysm sac rupture. In patients with AAA at adequately low surgical risk and who may not be reliable for long-term follow-up, clinicians should consider the role of open repair to reduce long-term mortality risk.


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