Long-Term Outcomes Following Elective Repair of Intact Abdominal Aortic Aneurysms

Abstract

Objective: Compare long-term mortality, secondary intervention and secondary rupture following elective endovascular aneurysm repair (EVAR) and open surgical repair (OSR). Background: EVAR has surpassed OSR as the most common procedure used to repair abdominal aortic aneurysm (AAA), but evidence regarding long-term outcomes is inconclusive. Methods: We included patients in linked clinical registry and administrative data undergoing EVAR or OSR for intact AAA between January 2010 and June 2019. We used an inverse probability of treatment-weighted survival analysis to compare all-cause mortality, cause-specific mortality, secondary interventions and secondary rupture, and evaluate the impact of secondary interventions and secondary rupture on all-cause mortality.Results: The study included 3460 EVAR and 427 OSR patients. Compared to OSR, the EVAR all-cause mortality rate was lower in the first 30 days [adjusted hazard ratio (HR) = 0.22, 95% confidence interval (CI) 0.140.33], but higher between 1 and 4 years (HR = 1.29, 95% CI 1.12-1.48) and after 4years (HR = 1.41, 95% CI 1.23-1.63). Secondary intervention rates were higher over the first 30 days (HR = 2.26, 95% CI 1.11-4.59), but lower between 1 and 4years (HR = 0.59, 95% CI 0.48-0.74). Secondary aortic intervention rates were higher across the entire follow-up period (HR = 2.52, 95% CI 2.06-3.07). Secondary rupture rates did not differ significantly (HR = 1.06, 95% CI 0.73-1.55). Allcause mortality beyond 1 year remained significantly higher for EVAR after adjusting for any secondary interventions, or secendary rupture Conclusions: EVAR has an early survival benefit compared to OSR. However, elevated long-term mortality and higher rates of secondary aortic interventions and subsequent aneurysm repair suggest that EVAR may be a less durable method of aortic aneurysm exclusion.

Long-term Mortality and Reintervention After Endovascular and Open Abdominal Aortic Aneurysm Repairs in Australia, Germany, and the United States

“…Our finding of a consistent and early survival benefit of EVAR was supported by previous studies 9–16 . However, these studies showed varying lasting effects of the survival benefit ranging from 1 to 4 years 9–16 .…”

“…The EVAR-1 trial examined aneurysm-related reinterventions 9 . Others examined aneurysm and procedure-related reinterventions, the definition of which also differed across studies 10–12,15,16 . Our study focused on repeat AAA repair and found that across all 3 countries, the reintervention rates were 2% to 3% after OAR and 8% to 9% after EVAR at 7 years.…”

“…Our finding of a consistent and early survival benefit of EVAR was supported by previous studies. [9][10][11][12][13][14][15][16] However, these studies showed varying lasting effects of the survival benefit ranging from 1 to 4 years. [9][10][11][12][13][14][15][16] Some variation in the extent of the early survival benefit of EVAR seen across these country-specific studies may have been related to differences in study designs, such as enrollment years, patient population, and the nature of RCT versus real-world settings.…”

“…Reintervention rates at 5 years reported in previous studies ranged from just over 10% to almost 40%. [9][10][11][12]15,16 Definitions of reintervention in these studies varied markedly, making it challenging to interpret differences in reintervention rates across studies. The EVAR-1 trial examined aneurysm-related reinterventions.…”

“…Across these RCT and observational studies, the time point from which the early survival benefit related to EVAR disappeared and excess reinterventions after EVAR appeared varied (Supplemental Digital Content Table 1, http://links.lww.com/SLA/E357). The early survival benefit was lost after 1 to 1.5 years in some studies 10,11 and 3 to 4 years in a few others 12,15,16 . The differences in reinterventions between EVAR and OAR appeared as early as a few months after the initial procedure in the EVAR-1 trial 9 and as late as 9 years in the Open Versus Endovascular Repair (OVER) trial 11 .…”