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Comparative Effectiveness Of Endovascular Versus Open Repair Of Elective Abdominal Aortic Aneurysm In The Frail Medicare Population
Thomas Serena, DO1, Cali E. Johnson, M.D., Ed.D
1, Martha L. Weaver, MD
2, Dean J. Arnaoutakis, MD
3, Larry W. Kraiss, MD
1, Philip P. Goodney, MD, MS
4, Benjamin S. Brooke, MD, PhD
1.
1University of Utah, Salt Lake City, UT, USA,
2University of Virginia, Charlottesville, VA, USA,
3University of South Florida College of Medicine, Tampa, FL, USA,
4Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.
OBJECTIVES: Available evidence suggests equipoise between open aortic repair (OAR) or endovascular aneurysm repair (EVAR) for patients with anatomically suitable infrarenal abdominal aortic aneurysms (AAA). However, OAR is not often offered to frail patients with multimorbidity due to a perceived excessively high risk of morbidity and mortality associated with these procedures. The objective of this study was to compare outcomes among high-risk frail Medicare patients with infrarenal AAA who underwent OAR as compared to EVAR.
METHODS: The VQI Vascular Implant Surveillance and Interventional Outcomes Network (VISION) -Medicare linked database (2010-18) was used to identify patients undergoing EVAR and OAR and link their mortality via Medicare death records. After stratifying patients based on physiological risk using the validated VQI Frailty Index (<0.26 non-frail vs. >0.26 frail) we analyzed 30-day major adverse cardiac events (MACE) with logistic regression and 2-year mortality outcomes with Kaplan-Meier and Cox proportional hazard models.
RESULTS: We identified 3,208 frail patients who underwent elective EVAR (67%) or OAR (33%) procedure to treat an unruptured infrarenal AAA. Patients undergoing EVAR were older, more likely to be male and non-ambulatory, and more likely to be diagnosed with congestive heart failure, coronary artery disease, renal impairment, diabetes, and anemia when compared to patients undergoing OAR (p<0.01 for all comparisons). MACE outcomes were significantly higher among frail patients who underwent OAR as compared to EVAR (21% vs. 6%, P<0.001), which was confirmed following risk adjustment (OR 4.4; 95%CI:3.4-5.6; P<0.001). There was no difference in mortality among frail patients undergoing OAR as compared to EVAR during the initial 5-month period after surgery. After 5 months, there was a significant improvement in risk-adjusted survival among frail patients who underwent OAR as compared to EVAR that persisted at 2-years after surgery (P<0.001; Figure).
CONCLUSIONS: Among a contemporary cohort of higher-risk frail patients with elective infrarenal AAAs, OAR is associated with worse perioperative outcomes but ultimately offers superior 2-year survival when compared to EVAR. With the current EVAR-first paradigm in higher-risk patients, these data should be considered during surgical decision-making and OAR should not be considered prohibitive for frail older patients.
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