Abdominal Aortic Aneurysm Treatment in Finland

Study Questions:

How have changes in abdominal aortic aneurysm (AAA) treatment impacted prevalence, rupture rates, and mortality?

Methods:

The authors conducted a retrospective analysis of the Finnish Institute for Health and Welfare (for treated AAA) and Statistics Finland (for death due to AAA). Cases and procedures were identified using International Classification of Diseases, Tenth Revision (ICD-10) codes and procedure codes.

Results:

The annual incidence of ruptured AAA was 16.4 per 100,000 people over 50 years and decreased nearly 30% during the 15-year period. 52.5% of ruptured AAA patients died prehospital, and 13.4% of ruptured AAA patients who survived to the hospital were not repaired. Women had a higher age-adjusted operative mortality following ruptured AAA repair (48.1% vs. 39.0% for men). A total of 4,956 intact AAA repairs were performed during the study period. Endovascular repair (EVAR) accounted for 33.2%, increasing from 18.4% in 2000-2004 to 49.8% in 2010-2014. Proportions of open repair versus EVAR varied by geographic regions, however, with some regions maintaining open repair rates >90% throughout the study period. Mortality associated with elective repair dropped from 6.3% in 2000-2004 to 2.7% in 2010-2014. For intact AAA, women had lower rates of intact AAA repair (3.8% per 100,000 per year vs. 31.3% for men), but similar mortality rates (3.9% vs. 4.0% for men). Women also had a higher median age at time of intact AAA repair (76 vs. 72 years). Median estimated survival after intact AAA repair was 8.6 years. The most common causes of death after 90 days following AAA repair were cardiovascular disease (mainly coronary disease or stroke) and cancer. AAA-related death was more common after 90 days in the EVAR group (5.8% vs. 1.9%).

Conclusions:

Declines in ruptured AAA and perioperative mortality following repair of intact AAA may reflect increased use of EVAR and improved mortality rates associated with both EVAR and open surgical repair. Late AAA-related mortality is higher following elective EVAR compared to open repair.

Perspective:

Despite declines in ruptured AAA during the study period, over 50% of patients with this diagnosis died before reaching the hospital. These observations suggest that screening and surveillance remain important for lowering AAA mortality at population levels. All EVARs in this study were performed at five academic centers, suggesting the possibility that systems issues (such as EMS systems and access to high-volume centers) may offer opportunities for lowering mortality even further. Considerable geographic variation in AAA repair approaches was identified in Finland (with a population of approximately 5.5 million people). It is likely that similar or greater variation may exist in countries with larger geographic areas and more variability in population density, particularly those where health systems are often subdivided into states, counties, or provinces and segregated by insurance status. Gender disparities in this study included lower rates of intact repair, older age at time of intact AAA repair, and higher mortality rates following ruptured AAA among women. Similar findings have been reported by others, and these observations suggest that awareness and screening initiatives targeting women with AAA are warranted.


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