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Comparison of Outcomes after Endovascular and Open Repair of Abdominal Aortic Aneurysms in Low Risk Patients in the Vascular Study Group of New England
Jeffrey J. Siracuse, M.D., Marc L. Schermerhorn, M.D., Andrew J. Meltzer, M.D., Jeffrey A. Kalish, M.D., Mohammad H. Eslami, M.D., Denis Rybin, M.S., Gheorghe Doros, Ph.D., Alik Farber, M.D..
Boston University, Boston, MA, USA.

Objectives: Although endovascular aortic aneurysm repair (EVAR) of abdominal aortic aneurysms (AAA) has been shown to have superior perioperative outcomes compared to open surgical repair (OSR) overall, perioperative and longer-term outcomes in low risk patients are unclear. Our objective was to analyze outcomes in this low risk cohort.
Methods: We performed a retrospective review of all infrarenal AAA patients undergoing EVAR and OSR in the Vascular Study Group of New England (VSGNE) database. The Medicare scoring system was used to identity low risk patients: male, age<75, no renal insufficiency, congestive heart failure, peripheral vascular disease, or cerebrovascular disease. Only OSR with an infrarenal clamp were included and patients with major concomitant procedures were excluded. EVAR and OSR patients were compared using t-test and Fisher’s exact test. Multivariable analysis was used for long-term survival and reinterventions.
Results: There were 1070 EVAR and 476 OSR with an infrarenal clamp performed in low risk AAA patients. The average age in EVAR and OSR cohorts was 67.3±5.7 and 65.5±6.3 (P<.001), respectively. EVAR patients had significantly higher rates of diabetes (19.3% vs. 12.4%, P<.001) and hypertension (81.5% vs. 76.8%, P=.038). The EVAR cohort had lower postoperative MI (0.7% vs. 3.4%, P<.001), CHF (0.6% vs. 1.9%, P=.021), pulmonary complications (0.7% vs. 5.7%, p<.001), worsening renal function (1.3% vs. 7.4%, p<.001), bowel ischemia (0.1% vs. 1.7%, p<.001), return to OR (0.7% vs. 4%, p<.001), and risk of any complication (4.3% vs. 27.8%, p<.001). There was no difference in 30 day mortality (0.4% vs. 0.6%, P=.446), however EVAR had a lower rate of major cardiac adverse events (MACE) (death, MI, stroke) (1.9% vs. 9.5%, P<.001). Kaplan-Meier life table analysis shows no difference in survival at three years (93% vs. 93%, P=.995). In multivariable analyses there was no difference in long-term survival (HR .85, 95% CI .61-1.2, P=.353). There was also no difference between EVAR and OSR in freedom from re-intervention within one year (OR 1.69, 95% CI .73-3.9, P=.22).
Conclusion: Although EVAR in low risk patients has fewer perioperative complications compared with OSR, there is not a short or long-term survival benefit. There were no differences in re-interventions within one year, however more long-term data is needed for this population with an expected prolonged postoperative survival.

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