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The Impact Of Reintervention After Endovascular Repair Of Infrarenal And Complex Abdominal Aortic Aneurysms On 5-year Survival
Sai Divya Yadavalli, MD1, Winona Wu, MD
1, Vinamr Rastogi
2, Jorge Gomez-Mayorga, MD
1, Nicholas Swerdlow, MD
3, Sara L. Zettervall, MD
4, Marc L. Schermerhorn, MD
1;
1BIDMC, Boston, MA, USA,
2Erasmus University Medical Center, Rotterdam, Netherlands,
3Brigham and Women's Hospital, Boston, MA, USA,
4University of Washington, Seattle, WA, USA
Objective: While reintervention following EVAR is thought to poorly impact long-term survival, studies evaluating the same following complex AAA repair are limited. We examined the impact of any reintervention on 5-year survival in patients undergoing endovascular aortic aneurysm repair, accounting for the time-varying occurrence of reintervention.
Methods: We identified patients who underwent elective first-time AAA and complex AAA (suprarenal/pararenal/juxtarenal aneurysms) repair between 2014 and 2019 in the VQI linked
with Medicare claims. Multivariable Cox-regression analysis was performed with any reintervention after discharge from the index admission as a time-varying covariate to evaluate its impact on 5-year mortality, adjusting for potential confounders. We also assessed the impact of reintervention based on its timing from the index repair (
<30 days, 30-365 days, >365 days).
Results: We identified 26,499 EVARs and 1,251 FEVARs (23% physician modified, 77% commercial custom made devices) with 5-year reintervention estimates of 18% and 48%. EVAR patients undergoing any reintervention were slightly younger, more likely to be male, had higher rates of hypertension, congestive heart failure, preoperative anemia, and more commonly had the procedure at low volume centers and by low volume physicians (all p<.05). Through 5-years, undergoing any reintervention was associated with higher hazards of mortality compared with no reintervention (adjusted hazard ratio (aHR): 1.90[1.65-2.19];p<.001). Mortality hazards remained higher for the reintervention group irrespective of timing (Table).In the FEVAR cohort, there were no differences in demographics or comorbidities, however, the reintervention group had larger preoperative aneurysm diameters, longer procedure times, and fluoroscopy times (all p<.05). Through 5-years, any reintervention was associated with higher 5-year mortality compared with no reintervention (aHR: 1.51[1.08-2.13];p=.017). Similar findings were seen in patients who had reinterventions beyond 30 days following the index procedure (Table). Nevertheless, reintervention within 30 days of the index procedure was associated with similar 5-year mortality (aHR: 0.56[0.18-1.76];p=.32) relative to no reintervention.
Conclusion: Using robust methods, we found that any reintervention following EVAR and FEVAR was associated with higher 5-year mortality, except reintervention within 30 days after FEVAR. Further studies should evaluate the impact of type and severity of indication for reintervention on long-term survival following endovascular aortic repair.
|
| | Hazard ratio | 95% Confidence Interval | P-value |
| EVAR | Reintervention (ref no reintervention) | 1.90 | 1.65-2.19 | <.001 |
| Time of reintervention | | | |
| No reintervention | Ref | - | - |
| <30 days | 1.61 | 1.92-2.54 | <.001 |
| 31-365 days | 1.69 | 2.18-4.15 | <.001 |
| >365 days | 2.35 | 1.91-2.88 | <.001 |
| FEVAR | Reintervention (ref no reintervention) | 1.51 | 1.08-2.13 | .017 |
| Time of reintervention | | | |
| No reintervention | Ref | - | - |
| <30 days | 0.56 | 0.18-1.76 | .32 |
| 31-365 days | 1.68 | 1.06-2.68 | .028 |
| >365 days | 1.84 | 1.12-3.05 | .017 |
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