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Comparison of Long-Term Survival After Open vs Endovascular Repair of Intact Abdominal Aortic Aneurysm Among Medicare Beneficiaries
Study Questions:
What are the long-term outcomes after open versus endovascular repair of abdominal aortic aneurysm (AAA)?
Methods:
This was a retrospective analysis of patients 65 years or older in the Medicare Standard Analytic File, 2003-2007, who underwent isolated repair of intact AAA. Cause of death was determined from the National Death Index. The primary outcome measure was all-cause mortality. Secondary outcomes were AAA-related mortality, hospital length of stay, 1-year readmission, repeat AAA repair, incisional hernia repair, and lower extremity amputation.
Results:
Of 4,529 included patients, 703 were classified as having undergone open repair and 3,826 as having undergone endovascular repair. Mean and median follow-up times were 2.6 (standard deviation, 1.5) and 2.5 (interquartile range, 2.4) years, respectively. In unadjusted analysis, both all-cause mortality (173 vs. 752; 89 vs. 76/1,000 person-years, p = 0.04) and AAA-specific mortality (22 vs. 28; 11.3 vs. 2.8/1,000 person-years, p < 0.001) were higher after open versus endovascular repair. After adjusting for emergency admission, age, calendar year, sex, race, and comorbidities, there was a higher risk of both all-cause mortality (hazard ratio [HR], 1.24; 95% confidence interval [CI], 1.05-1.47; p = 0.01) and AAA-related mortality (HR, 4.37; 95% CI, 2.51-7.66; p < 0.001) after open versus endovascular repair. The adjusted hospital length of stay was, on average, 6.5 days (95% CI, 6.0-7.0 days; p < 0.001) longer after open repair (mean, 10.4 days), compared with endovascular repair (mean, 3.6 days). Incidence of incisional hernia repair was higher after open AAA repair (19 vs. 23; 12 vs. 3 per 1,000 person-years; adjusted HR, 4.45; 95% CI, 2.37-8.34; p < 0.001), whereas the incidence of 1-year readmission (188 vs. 1,070; 274 vs. 376/1,000 person-years; adjusted HR, 0.96; 95% CI, 0.85-1.09; p = 0.52), repeat AAA repair (15 vs. 93; 9.7 vs. 12.3/1,000 person-years; adjusted HR, 0.80; 95% CI, 0.46-1.38; p = 0.42), and lower extremity amputation (3 vs. 25; 1.9 vs. 3.3/1,000 person-years; adjusted HR, 0.55; 95% CI, 0.16-1.86; p = 0.34) did not differ by repair type.
Conclusions:
The authors concluded that among older patients with isolated intact AAA, use of open repair compared with endovascular repair was associated with increased risk of all-cause mortality and AAA-related mortality.
Perspective:
This study reports a long-term overall and AAA-specific survival advantage associated with endovascular repair of intact AAA, compared with open repair, in patients 65 years or older. The long-term survival advantage associated with endovascular repair persisted in multivariable analysis, suggesting that this relationship was likely independent of patient demographics, emergency presentation, and comorbidities. Furthermore, there was no evidence of differences in the hazard of rehospitalization within 1 year after AAA repair, repeat repair, or lower extremity amputation, comparing open versus endovascular repair, making endovascular repair an attractive modality in these patients. Given multiple limitations of this analysis, including use of administrative data, lack of information about aneurysm size or anatomical features, or use of secondary interventions performed on an outpatient basis, a randomized prospective study would be needed to confirm the benefits of endovascular repair.
Clinical Topics: Vascular Medicine
Keywords: Aortic Aneurysm, Abdominal
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