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Long-term Outcomes after Complex Abdominal Aortic Aneurysm Repairs among Patients Discharged Alive
Ambar Mehta1, Sai Divya Yadavalli, MD2, Jeffrey Siracuse, MD3, James Iannuzzi, MD4, Karan Garg, MD5, Marc Schermerhorn, MD2, Sara L. Zettervall6, Thomas F. X. O'Donnell, MD7, Virendra I. Patel, MD, MPH7.
1Massachusetts General Hospital, Boston, MA, USA, 2Beth Israel Deaconess Medical Center, Boston, MA, USA, 3Boston Medical Center, Boston, MA, USA, 4University of California San Francisco, San Francisco, MA, USA, 5New York University Langone Health, New York, NY, USA, 6University of Wisconsin Medical Center, Madison, WI, USA, 7NewYork-Presbyterian Columbia University Irving Medical Center, New York, NY, USA.

Objective: While complex abdominal aortic aneurysms (AAAs) have traditionally been repaired through open operations (cOARs), there has been a significant rise in endovascular repairs (cEVARs). We evaluated long-term outcomes among patients who were discharged alive after their index hospitalization, and how these outcomes varied by the presence of a postoperative complication.
Methods: We identified all elective complex AAA repairs in the 2014-2019 VQI-VISION registry, which couples the granularity of the Vascular Quality Initiative registry with Medicare long-term outcomes. Short-term outcomes included: perioperative mortality, complications, and failure-to-rescue. After dichotomizing patients who survived the index hospitalization into those that did not and those that did experience a postoperative complication, we evaluated two long-term outcomes: 3-year all-cause mortality and 3-year reinterventions. Multivariable logistic regressions and cox-proportional hazards models evaluated short-term and long-term outcomes, respectively.
Results: We identified 2271 patients (50% cOARs, 50% cEVARs). Relative to cOARs, cEVARs had lower rates of perioperative mortality (4.1% vs 5.0%, aOR 0.61 [95%-CI 0.40-0.95], P=.03) and complications (23% vs 42%, aOR 0.36 [0.29-0.45], P<.01) but similar rates of FTR (15% vs 10%, aOR 1.33 [0.75-2.37], P=.32). Among 2168 patients (95%) who were discharged alive, 1512 (70%) did not and 656 (30%) did have a postoperative complication. Among the patients discharged alive who did not have a postoperative complication (Figure), cEVARs had higher rates of 3-year all-cause mortality (24% vs 9.6%, aHR 1.92 [1.41-2.61], P<.01) and reinterventions (24% vs 5.6%, aHR 4.36 [2.85-6.67], P<.01). Similarly, among patients discharged alive who did have a postoperative complication (Figure), cEVARs had higher rates of both 3-year all-cause mortality (32% vs 20%, aHR 1.45 [1.01-2.09], P<.05) and reinterventions (24% vs 10%, aHR 2.43 [1.45-4.07], P<.01).
Conclusion: Our findings continue to support the observation that while cEVARs have lower short-term mortality and complications, they have higher 3-year all-cause mortality and reinterventions relative to cOARs, irrespective of the presence of a postoperative complication. Clinical decision making for open versus endovascular repair of complex aneurysms should take long term durability and survival into consideration, and ideally a randomized controlled trial for complex AAA repairs would make an important contribution in the care of these patients.


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