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Perioperative Outcomes After Endovascular Repair Of Large Complex Abdominal Aortic Aneurysms
Isa F. Van Galen, MD
1, Camila Guetter, MD, MPH
1, Elisa Caron, MD
1, Jeremy Darling, MD
1, Jemin Park, MD
1, Roger Davis, ScD
1, Mikayla Kricfalusi, BA
1, Joost A. van Herwaarden, MD
2, Virendra I Patel, MD, MPH
4, Thomas F. X. O'Donnell, MD
4, Marc L. Schermerhorn, MD
1.
1Divisions of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston MA, USA, 2Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, the Netherlands, 3Division of General Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, 4Division of Cardiac, Thoracic, and Vascular Surgery, New York-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, USA.
Objectives: EVAR for large AAAs has been associated with worse outcomes compared to EVAR for smaller AAAs. While open repair for large aneurysms has shown to be equivalent to open repair for smaller aneurysms, it is suggested to be more effective than EVAR for large AAAs. Whether these findings apply to cAAAs remains uncertain. Therefore, we investigated the association between aneurysm diameter and perioperative outcomes in patients undergoing cEVAR for cAAA.
Methods: We identified all cEVAR from 2012-2024 in VQI. cEVAR was defined as having proximal extent between zones 6-9 and at least one side branch. Aneurysm size was defined as follows: large: >65mm (men), >60mm (women); medium: 55-65mm (men), 50-60mm (women); and small: <55mm (men), <50mm (women). We assessed perioperative death, any complication, and in-hospital reintervention using logistic regression, and long-term mortality using Cox regression. Medium-sized aneurysms were compared to large and small aneurysms.
Results: Of 3,304 patients (75.4% male), 21% had large, 62% medium, and 17% had small aneurysms. Rates of perioperative death, any complication, and in-hospital reintervention were higher for large compared with medium and small (4.3% vs. 2.6% vs. 0.5%; 32.1% vs. 23.5% vs. 19.1%; 6.0% vs. 3.9% vs. 2.5%, respectively; all p <.05). Median follow-up was 450 days. One-year mortality rates were higher in large aneurysms (11.4% vs. 7.8% vs. 3.9%; p <.001). After adjustment, when compared to medium-sized aneurysms, large aneurysms were associated with a 45% higher risk of death during follow-up (aHR1.45; 95%CI[1.14-1.83]), while small aneurysms did not demonstrate a difference (0.79[0.57-1.09]) (Figure 1). Large and small aneurysms were associated with higher and lower risks, respectively, of perioperative death (large: aOR1.63[1.01-2.59]; small: 0.27[0.06-0.74]), any complication (large: 1.37[1.11-1.68]; small: 0.86[0.67-1.09]), and in-hospital reintervention (large: 1.52[1.02-2.25]; small: 0.80[0.43-1.39]) when compared with medium-sized aneurysms.
Conclusions: In cEVAR for cAAA, large aneurysms were associated with higher rates of perioperative death, any complication, in-hospital reintervention, and long-term mortality compared with medium-sized aneurysms. While these results align with expectations, they emphasize the importance of effectively managing patients with large cAAAs, highlighting the need for future research to determine whether medically fit patients might benefit more from open repair.
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