Risks of Aortic-Related Reintervention or Rupture are Lower in Open Compared to Endovascular Abdominal Aortic Aneurysm Repair
Nathan L. Liang, MD, MS, Michel S. Makaroun, MD, Rabih A. Chaer, MD, MSc, Edith Tzeng, MD.
University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
OBJECTIVE: The objective of this study is to compare perioperative outcomes and long-term reintervention rates after elective open and endovascular (EVAR) abdominal aortic aneurysm repair in a large population-based cohort.
METHODS: Subjects undergoing non-ruptured open repair or EVAR were identified using longitudinally-linked Florida state inpatient and ambulatory surgery databases from 2004-2014 encompassing subjects of all ages and insurance providers. Perioperative outcomes and long-term reintervention rates were compared between open and EVAR. A separate subgroup analysis of patients under age 65 was performed.
RESULTS: We identified 33,276 subjects undergoing EVAR (74.3%, n=24,725) or open repair (25.7%, n=8551). The EVAR group was older (EVAR: 74.3±8 years; open: 71.7±8.7yr; P<0.001). The EVAR group had lower in-hospital mortality overall (EVAR: 1.1%, n=270; open: 5.3%, n=457; P<0.001) and for the younger subgroup (EVAR: 0.3%, n=13; open: 2.7%, n=53; P<0.001). The EVAR group also had shorter median length of stay (EVAR: 2d, IQR 0-5; open: 4d, IQR 1-7; P<0.001) but did not differ for 30-day all-cause readmissions (EVAR: 10.8%, n=2660; open: 11.5%, n=983; P=0.06). The EVAR group had inferior freedom from first major open aortic reintervention or rupture at 5 years in the overall cohort (EVAR: 95±0.3%, open: 98±0.2%; log-rank P<0.001) and in the younger subgroup (EVAR: 96±0.4%, open: 98±0.4%; log-rank P<0.001) compared to open repair. Propensity-matched negative binomial regression models were used to account for multiple reinterventions, showing that open repair had significantly lower risk for any aortic-related reintervention, major open aortic reintervention, or any reintervention including incisional hernia repair and operations for bowel obstruction. Analysis of the 65-and-under subgroup also showed open repair with significantly lower risks of aortic-related and major open aortic reintervention but did not demonstrate a difference for long-term reintervention when including incisional hernia repair and operations for bowel obstruction (Table).
CONCLUSIONS: This population-based study demonstrates lower risks of long-term reintervention or rupture after open repair, offset by higher perioperative mortality rates, compared to EVAR. This offset is diminished in younger patients due to lower perioperative mortality rates overall, but at a higher potential risk of laparotomy-related complications after open repair.
| Overall Cohort RR (95% CI) | P | Younger Cohort RR (95% CI) | P | |
| Aortic Related Reintervention | 0.54 (0.47-0.63) | <0.001 | 0.53 (0.39-0.73) | <0.001 |
| Major Open Aortic Reintervention | 0.37 (0.29-0.48) | <0.001 | 0.50 (0.28-0.90) | 0.02 |
| Any Reintervention | 0.75 (0.66-0.86) | <0.001 | 1.04 (0.76-1.43) | 0.8 |
| RR < 1 favors open repair | ||||
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