Early Mortality Benefit of EVAR vs. Open AAA Repair Holds up Long-term

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The well-established early mortality advantage for endovascular vs. open repair of abdominal aortic aneurysm (AAA) persists out to 5 years, according to a study published in the April 18, 2012, issue of the Journal of the American Medical Association.

In a retrospective analysis, Rubie Sue Jackson, MD, MPH, of Georgetown University Hospital (Washington, DC), and colleagues compared overall and AAA-specific mortality, readmission, and reintervention in 4,529 Medicare patients undergoing open (n = 703) or endovascular aortic aneurysm repair (EVAR; n = 3,826) of isolated, intact AAA from 2003 through 2007.

Short-term Advantage Not Lost

Mean follow-up was 2.6 years with a maximum of 5.7 years. Both all-cause mortality (89 vs. 76 deaths/1,000 person-years; P = 0.04) and AAA-specific mortality (11.3 vs. 2.8 deaths/1,000 person-years; P < 0.001) were higher after open surgical repair vs. EVAR.

After adjusting for multiple variables including emergency admission, age, calendar year, sex, race, and comorbidities, all-cause mortality, the primary outcome, remained 24% higher after open vs. endovascular repair, while AAA-specific mortality was 4.4 times higher. Incidence of incisional hernia repair was also higher after open AAA repair, while other secondary outcomes did not differ by repair type (table 1).

Table 1. Primary and Secondary Outcomes, Open Repair vs. EVAR

Patients who underwent open repair also had longer adjusted hospital lengths of stay compared with those who received EVAR (10.4 days vs. 3.6 days; P < 0.001).

In sensitivity analyses excluding comorbidities that could not be differentiated from complications or patients who underwent repair during emergency admission, results of the various outcomes were similar to those of the main analysis.

According to the authors, the persistence of the survival advantage in the multivariable analyses suggests that it exists independent of patient demographics, emergency presentation, and comorbidities. They also note that the substantially increased risk for incisional hernia repair among patients who underwent open AAA surgery “deserves mention because comparisons of reintervention after open vs. endovascular AAA repair have sometimes overlooked incisional hernia repair.”

Data Reassuring to Clinicians

A perioperative survival advantage of EVAR over open surgical repair has been reported in both the EVAR1 (Endovascular Aneurysm Repair 1) and OVER (Open Versus Endovascular Repair) trials. However, the survival advantage was not significant in either trial at 2 years.

“The present study demonstrates an even longer survival advantage of endovascular over open repair, which was maintained throughout the entire 5.7 years of follow-up,” Dr. Jackson and colleagues write. “Improved durability of endovascular repair over time, as well as the large sample size of the present study, may be important in explaining differences between the findings presented here and those of earlier and smaller studies.”

In a telephone interview with TCTMD, Robert M. Bersin, MD, of Swedish Medical Center (Seattle, WA), disagreed slightly with the authors’ assessment, noting that the same second-generation devices used today were used in both EVAR 1 and OVER, making it unlikely to be an issue of durability.

“I think the difference honestly may be case selection,” said Dr. Bersin, a spokesperson for the Society for Cardiovascular Angiography and Interventions. “We’ve learned over the years who does well with these devices and who doesn’t. It’s been an evolution of not just what devices and adjunctive therapies are used, but also proper patient selection.”

Dr. Bersin said the study is an important, albeit nonrandomized, addition to the literature.

“I think this study provides very valuable information because about 80% of all aneurysm repairs performed in the United States today are done with endografts,” he said. “So, it’s reassuring to the physicians who are doing these treatments to know that what they are doing [is not only] minimally impactful upfront [but] is providing a long-term benefit as well. I think [the accumulated data] will pretty much put an end to the question of whether or not the short-term benefit is maintained.”

 

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Source:
Jackson RS, Chang DC, Freischlag JA. Comparison of long-term survival after open vs. endovascular repair of intact abdominal aortic aneurysm among Medicare beneficiaries. JAMA. 2012;307:1621-1628.

 

 

Related Stories:

• Early Survival Advantage of TEVAR Over Surgery Reversed Over Long Term
• Endovascular Approach Takes Lead Over Surgery for AAA Repair
• Trials Show EVAR Provides No Long-term Mortality Benefit for AAA Patients

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