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Does Aneurysm Size Matter?: Lack of Adherence to Diameter Threshold Criteria for Repair of Abdominal Aortic Aneurysms
Jaime Benarroch-Gampel, MD, MS, Thomas J. Desmarais, MD, Gregorio A. Sicard, MD, Brian G. Rubin, MD.
Washington University School of Medicine, St. Louis, MO, USA.
OBJECTIVES:
Guidelines from the SVS and AHA recommend elective repair in asymptomatic patients with an Abdominal Aortic Aneurysm (AAA) with a diameter equal to or greater than 5.5cm. The objective of this study is to evaluate adherence to that guideline by physicians performing AAA repair.
METHODS:
Patients who underwent elective endovascular (EVAR) or open (OAAR) repair of an infrarenal AAA were abstracted from the 2011-2013 Targeted National Surgical Quality Improvement Program (NSQIP) database. Because of the absence of clear diameter threshold criteria for treatment of women with AAA, only males with diameter as the indication for repair were included. Multivariate analysis were performed to identify factors associated with repair of small AAA (less than 5.5cm).
RESULTS:
A total of 2,691 (89%) patients underwent EVAR while 334 (11%) underwent OAAR. The mean diameter for repair in patients who underwent OAAR was 6.2cm (IQR 5.3-6.7 cm) while for patients treated with EVAR it was 5.7cm (IQR 5.1-6 cm). However, in 43.1% of EVAR and 32.3% of OAAR patients, the diameter of the AAA was 5.4 cm or less at the time of the repair; 21.4% of EVAR and 17.3% of OAAR patients had a diameter of 5cm or smaller. The group undergoing small AAA repair was younger (40.9% vs. 33.8% younger than 70y old, P<.0001) and less likely to have chronic obstructive pulmonary disease compared to patients operated on with an AAA diameter of at least 5.5 cm. When compared to patients younger than 60y old, patients between 60-69y were 18% less likely (OR=0.82, 95% CI=0.68-0.99), patients between 70-79y were 29% less likely (OR=0.71, 95% CI=0.58-0.77) and patients 80y or older were 50% less likely (OR=0.50, 95% CI=0.40-0.63) to have a repair of small AAA. Additionally, patients who underwent EVAR were 75% more likely to have a small AAA repaired compared with those who underwent OAAR (OR 1.75, 95% CI=1.37-2.25). Regardless of AAA size at the time of repair, there was no difference in 30-days postoperative morbidity and mortality between groups.
CONCLUSIONS:
Lack of adherence to evidence based guidelines for AAA repair is frequent. We found a high rate of repair of asymptomatic AAA in men with a diameter of 5.4 cm or less, more common in patients undergoing EVAR than OAAR.
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