Real world outcome: Open versus Endovascular repair of ruptured Abdominal Aortic Aneurysm
Akshay Kumar Gupta, MD MPH, Besma Nejim, MD MPH, Hanaa Aridi, MD, Muhammad Rizwan, MD, Satinderjeet locham, MD, Mahmoud Malas, MD, MHS, RPVI, FACS.
Johns Hopkins Medical Institutions, Baltimore, MD, USA.
Objective: Majority of the prior studies including randomized control trials (RCT) failed to provide sufficient evidence of superiority of endovascular repair (EVAR ) over open repair for ruptured abdominal aortic aneurysm (rAAA). This ambiguity is in parts due to small study size, patient selection bias, poor study design, single insurance type and improper adjustment for comorbidities. This study aim to provide real world outcomes of endovascular verses open repair of rAAA.
Methods: Retrospective observational cohort study was performed in the prospectively collected Premier Hospital database between July 2009 and Mar 2015. Patients with rAAA diagnosis and their perspective comorbidities, operative procedures and complications were identified using ICD-9 codes. Patients who had undergone both open and endovascular procedures were excluded. Coarsened exact matching was performed based on demographic, insurance status, hospital characteristics and surgical specialty performing the procedure. Multivariate logistic regression model was operated on matched pairs to identify predictors of in-hospital mortality and complications. Potential 10 confounders were included in the final adjusted model.
Results: There were total of 3164 patients with rAAA. There were 1,550 (49.0%) open repair and 1,614(51.0%) EVAR. There was significant difference in demographic characteristics between the two groups except for gender, location (urban vs rural) and insurance types. Comorbidities were found to be similar except for alcoholism and cerebrovascular diseases (table 1). The endovascular group had 23.79% mortality while open repair had 36.26% mortality (p <0.001). Matching resulted in 458 patients in endovascular and 402 in open repair group. The adjusted odds ratio of mortality was 1.76 (95% CI, 1.31-2.37, p value<0.001), cardiac complication (1.63, p value<0.05), pulmonary failure (2.06, p value <0.001), renal failure (1.69, p value <0.001), bowel ischemia (1.94, p value<0.05) significantly higher for open repair compared to EVAR.
Conclusion: In this matched cohort of patients representing real world outcomes, open repair has 76% higher mortality than EVAR for rAAA irrespective of patients‘ demographics, comorbidities and insurance status. The morbidities of open repair was also significantly higher. Well-designed RCT are needed to further confirm the benefit of EVAR in rAAA. Table 1 Characteristics of ruptured AAA patients in Premier Hospital database, 2009-2015
| Total (n=3164) | EVAR (n=1614) | Open Repair (n=1550) | P value | |
| Age | 73.12(9.56) | 73.59(9.7) | 72.66(9.4) | <0.01 |
| Gender Male (%) Female (%) | 76.01 23.99 | 76.95 23.05 | 75.03 24.97 | 0.21 |
| Married (%) | 48.29 | 47.46 | 49.16 | 0.02 |
| Race (%) White | 78.26 | 79.62 | 76.84 | 0.02 |
| Black | 6.04 | 6.44 | 5.61 | |
| Other | 15.71 | 13.94 | 17.55 | |
| Region (%) Midwest | 17.91 | 13.99 | 21.99 | <0.001 |
| Northeast | 16.61 | 18.53 | 14.62 | |
| South | 46.86 | 46.46 | 47.28 | |
| West | 18.61 | 21.02 | 16.11 | |
| Location Urban (%) Rural (%) | 90.74 9.26 | 90.73 9.27 | 90.75 9.25 | 0.987 |
| Length of Stay Mean(SD) | 10.47 | 8.36(9.56) | 12.67(12.70) | <0.01 |
| Hospital (%) Teaching | 51.78 | 55.35 | 48.06 | <0.001 |
| Surgical Speciality Internal radiology | 14.85 | 14.93 | 14.77 | <0.001 |
| Cardiothoracic | 15.08 | 12.76 | 17.48 | |
| General Surgery | 14.16 | 12.64 | 15.74 | |
| Vascular Surgery | 41.78 | 45.48 | 37.94 | |
| Vascular + Interventional | 0.2 | 0.1 | 0.3 | |
| Others | 13.94 | 14.06 | 13.81 | |
| Insurance (%) Medicare | 74.53 | 75.40 | 73.61 | 0.25 |
| Medicaid | 3.29 | 3.10 | 3.48 | |
| Managed Care | 11.57 | 11.90 | 11.23 | |
| Commercial | 4.24 | 3.53 | 4.97 | |
| Other | 6.38 | 6.07 | 6.71 | |
| Comorbidities Hypertension (%) | 72.53 | 73.48 | 71.55 | 0.22 |
| Diabetes (%) | 17.95 | 18.96 | 16.90 | 0.13 |
| Obesity (%) | 14.16 | 14.37 | 13.94 | 0.72 |
| Any Smoking (%) | 53.73 | 54.52 | 52.90 | 0.36 |
| Alcoholism (%) | 5.59 | 4.65 | 6.58 | 0.02 |
| Hypercholesterolemia (%) | 40.64 | 41.95 | 39.29 | 0.13 |
| Ischemic Heart Disease2 (%) | 41.18 | 42.69 | 39.61 | 0.08 |
| Cerebro-Vascular Disease3 (%) | 10.68 | 13.20 | 8.06 | <0.001 |
| COPD (%) | 32.36 | 31.97 | 32.77 | 0.63 |
| Chronic Kidney Disease4 (%) | 22.25 | 21.93 | 22.58 | 0.66 |
| Dialysis (%) | 3.07 | 2.85 | 3.29 | 0.47 |
| Critical Limb Ischemia5 (%) | 0.32 | 0.37 | 0.26 | 0.57 |
| Peripheral Vascular Disease (%) | 22.91 | 23.36 | 22.45 | 0.54 |
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