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Long-Term Outcomes Associated With Open vs. Endovascular AAA Repair
Quick Takes
- Open AAA repair was associated with higher odds of 30-day mortality and perioperative complications but lower rates of 6-year mortality, rupture, and reintervention, compared with EVAR.
- Higher risk of late-term adverse events and mortality were observed in the overall cohort as well as the propensity-matched subgroups.
Study Questions:
What are the long-term outcomes associated with endovascular abdominal aortic aneurysm repair (EVAR) compared with open aneurysm repair?
Methods:
This multicenter retrospective cohort study evaluated long-term outcomes in a cohort of patients undergoing first-time elective EVAR or open abdominal aortic aneurysm (AAA) repair from 2003–2018. Six-year follow-up outcomes were assessed using the Medicare-matched Vascular Quality Initiative (VQI) Vascular Implant Surveillance and Interventional Outcomes Network (VISION) database. Propensity matching based on 21 characteristics was used to produce a balanced subgroup cohort of 2,842 patients in each group due to significant baseline differences in the larger group. Patients with ruptured AAA, concomitant procedures, or prior history of AAA repair were excluded. The primary long-term outcome of interest was 6-year all-cause mortality, rupture, and reintervention. Secondary outcomes included 30-day mortality and perioperative complications.
Results:
A total of 32,760 patients were initially identified, among whom 28,281 underwent EVAR and 4,479 underwent open repair. Over 6 years in the unmatched cohort, patients who underwent open aneurysm repair, compared with those who underwent EVAR, had significantly lower rates of mortality (1,058 deaths [34.9%] vs. 6,348 deaths [43.5%]; p < 0.001), rupture (197 patients [5.6%] vs. 1,385 patients [7.7%]; p < 0.001), and reintervention (329 patients [9.8%] vs. 2,619 patients [15.3%]; p < 0.001). Analysis of the propensity-matched subgroup with 2,842 patients in each category revealed that open repair was associated with significantly lower 6-year mortality compared with endovascular repair (548 deaths [35.6%] vs. 608 deaths [41.2%]; hazard ratio [HR], 0.83; 95% confidence interval [CI], 0.74-0.94; p = 0.002), with increases in mortality starting from 1-2 years (84 deaths [4.3%] vs. 126 deaths [6.7%]; HR, 0.63; 95% CI, 0.48-0.83; p = 0.001) and 2-6 years (211 deaths [25.8%] vs. 241 deaths [30.6%]; HR, 0.73; 95% CI, 0.61-0.88; p = 0.001).
Conclusions:
Open AAA repair was associated with higher odds of 30-day mortality and perioperative complications but lower rates of 6-year mortality, rupture, and reintervention. Conversely, EVAR had early (perioperative) advantages but inferior long-term outcomes. These findings support vigilant long-term surveillance during long-term EVAR follow-up and careful consideration of short-term and long-term outcomes tradeoffs when choosing a primary AAA repair strategy, especially for patients who are low-risk candidates for open repair.
Perspective:
The results of this study contribute to a growing body of evidence based on large-scale cohort studies suggesting inferior late outcomes associated with EVAR versus open surgical repair of AAA. These observations are distinct from the large randomized clinical trials referenced in the paper, where similar long-term outcomes were observed. A key consideration linked to this difference in outcomes by study designs (mentioned by the authors in their discussion) may be off-label use of EVAR in patients whose aortic anatomy is not within device-specific instructions for use. Although the database used in this analysis does not contain anatomic details to confirm this hypothesis, it seems likely that off-label use (which would not be an issue within a trial with strict anatomic inclusion criteria) would contribute to risk for post-EVAR endoleaks, aneurysm growth, and reinterventions including conversion to open repair. It is noteworthy that incisional hernias, which have been a major source of repeat intervention following open aneurysm repair in other studies, were not included among late outcomes in this analysis.
When offered the tradeoff, many patients prefer the higher risk of reintervention or aneurysm rupture in the more distant future with EVAR over the higher short-term risk of death or adverse perioperative events with open repair. In the world of economics, this is known as time discounting, and it is easy to appreciate a preference to experience risk in the future rather than upfront. Patients who experience post-EVAR rupture or reinterventions (sometimes culminating in conversion to open repair), however, do not get a tradeoff and instead are exposed to the downside of both options.
Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Prevention, Vascular Medicine, Aortic Surgery, Cardiac Surgery and Arrhythmias, Interventions and Vascular Medicine
Keywords: Aortic Aneurysm, Abdominal, Aortic Rupture, Cardiac Surgical Procedures, Cardiology Interventions, Endoleak, Endovascular Procedures, Outcome Assessment, Health Care, Perioperative Care, Risk Assessment, Secondary Prevention, Vascular Diseases
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