Long-term Outcomes Associated With Open vs Endovascular Abdominal Aortic Aneurysm Repair in a Medicare-Matched Database

Abstract

IMPORTANCEEndovascular aneurysm repair is associated with a significant reduction in perioperative mortality and morbidity compared with open aneurysm repair in the treatment of abdominal aortic aneurysm. However, this benefit decreases over time owing to increased reinterventions and late aneurysm rupture after endovascular repair. OBJECTIVE To compare long-term outcomes of endovascular vs open repair of abdominal aortic aneurysm. DESIGN, SETTING, AND PARTICIPANTS This multicenter retrospective cohort study used deidentified data with 6-year follow-up from the Medicare-matched Vascular Quality Initiative Vascular Implant Surveillance and Interventional Outcomes Network database. Patients undergoing first-time elective endovascular or open abdominal aortic aneurysm repair from 2003 to 2018 were propensity score matched. Patients with ruptured abdominal aortic aneurysm, concomitant procedures, or prior history of abdominal aortic aneurysm repair, were excluded. Data were analyzed from January 1, 2003, to December 31, 2018. EXPOSURES First-time elective endovascular or open repair for abdominal aortic aneurysm. MAIN OUTCOMES AND MEASURES 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 Among a total of 32 760 patients (median [IQR] age, 75 [70-80] years; 25 706 [78.5%] men) who underwent surgical abdominal aortic aneurysm repair, 28 281 patients underwent endovascular repair and 4479 patients underwent open repair. After propensity score matching, there were 2852 patients in each group. 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% CI, 0.74-0.94; P = .002), with increases in mortality starting from 1 to 2 years(84 deaths [4.3%] vs 126 deaths [6.7%]; HR, 0.63; 95% CI, 0.48-0.83; P = .001) and 2 to 6 years (211 deaths [25.8%] vs 241 deaths [30.6%]; HR, 0.73; 95% CI, 0.61-0.88; P = .001). Open repair, compared with endovascular repair, also was associated with significantly lower rates of 6-year rupture (117 participants [5.8%] vs 149 participants [8.3%]; HR, 0.76; 95% CI, 0.60-0.97; P < .001) and reintervention (190 participants [11.6%] vs 267 participants [16.0%]; HR, 0.67; 95% CI, 0.55-0.80; P < .001). Open repair was associated with significantly higher odds of 30-day mortality (OR, 3.56; 95% CI, 2.41-5.26; P < .001) and complications. CONCLUSIONS AND RELEVANCEThese findings suggest that overall mortality after elective abdominal aortic aneurysm repair was higher with endovascular repair than open repair despite reduced 30-day mortality and perioperative morbidity after endovascular repair. Endovascular repair (continued) Key Points Question What are the long-term outcomes associated with endovascular abdominal aortic aneurysm repair compared with open aneurysm repair? Findings In this cohort study of 32 760 abdominal aortic aneurysm repairs in a Me...

Using Registry Data to Fill Blind Spots From Randomized Trials of Abdominal Aortic Aneurysm Repair

“…mortality between OAR and EVAR, the results in this study indicate that, in practice, long-term outcomes may be superior among patients who undergo OAR. 2,5 In addition, Yei et al 1 determined that there was an increased likelihood of reintervention among patients who underwent EVAR compared with those who underwent OAR. 5,6 Finally, Yei and coauthors 1 documented that patients who underwent EVAR experienced increased rates of late AAA rupture, despite their index aortic repair.…”

“…The findings described by Yei et al 1 highlight the importance of studying short and long-term results among patients undergoing surgical procedures in practice settings. Yei et al 1 Corresponding Author: Jesse A. Columbo, MD, MS, Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, 1 Medical Center Dr, Lebanon, NH 03766 (jesse.a.columbo@dartmouth.edu).…”

“…The study by Yei and coauthors describes 6-year results of abdominal aortic aneurysm (AAA) repair performed via open aneurysm repair (OAR) vs endovascular aneurysm repair (EVAR) using the Vascular Quality Initiative (VQI) Vascular Implant Surveillance and Interventional Outcomes Network (VISION) registry, a multicenter registry that collects granular clinical data on the patients and procedures and links it with Medicare claims for long-term follow up. Among a cohort of more than 32 000 patients, Yei et al determined that despite an increased perioperative mortality associated with OAR compared with EVAR, patients treated with OAR experienced superior long-term outcomes.…”

“…The study by Yei and coauthors describes 6-year results of abdominal aortic aneurysm (AAA) repair performed via open aneurysm repair (OAR) vs endovascular aneurysm repair (EVAR) using the Vascular Quality Initiative (VQI) Vascular Implant Surveillance and Interventional Outcomes Network (VISION) registry, a multicenter registry that collects granular clinical data on the patients and procedures and links it with Medicare claims for long-term follow up. Among a cohort of more than 32 000 patients, Yei et al determined that despite an increased perioperative mortality associated with OAR compared with EVAR, patients treated with OAR experienced superior long-term outcomes. Specifically, patients who underwent OAR, compared with propensity score–matched patients who underwent EVAR, had decreased 6-year mortality (548 deaths [35.6%] vs 608 deaths [41.2%]; hazard ratio [HR], 0.83; 95% CI, 0.74-0.94; P = .002), were less likely to experience late AAA rupture after their index repair (117 participants [5.8%] vs 149 participants [8.3%]; HR, 0.76; 95% CI, 0.60-0.97; P < .001), and were less likely to require reinterventions (additional procedures after the initial repair to treat their AAA) (190 participants [11.6%] vs 267 participants [16.0%]; HR, 0.67; 95% CI, 0.55-0.80; P < .001).…”

“…Results from Yei et al using the VISION registry have important implications for patients considering AAA repair. First, while prior randomized studies documented no difference in long-term mortality between OAR and EVAR, the results in this study indicate that, in practice, long-term outcomes may be superior among patients who undergo OAR .…”