EVAR Safer Than Surgery Even in Low-Risk Men

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Low-surgical-risk men with abdominal aortic aneurysm (AAA) who receive endovascular aneurysm repair (EVAR) have markedly lower rates of perioperative complications and early mortality than their counterparts who undergo open surgery, according to a registry study published online June 20, 2014, ahead of print in the Journal of Vascular Surgery. The authors acknowledge, however, that the choice of treatment must factor in longer-term outcomes.

Methods
Jeffrey J. Siracuse, MD, and colleagues from New York-Presbyterian Hospital/Weill Cornell Medical College (New York, NY), compared data on perioperative outcomes in matched cohorts of low-risk men with infrarenal AAA without visceral involvement who underwent either elective EVAR (n = 4,339) or open surgical repair (n = 1,576). All patients were enrolled in the prospective American College of Surgeons National Surgical Quality Improvement Program database between 2007 and 2010 and were deemed low risk according the Medicare aneurysm scoring system (< 3). Women and those aged at least 75 years or with a history of CHF, chronic renal insufficiency, peripheral vascular disease, or cerebrovascular disease were excluded because of the higher risk scores assigned to these demographic and clinical traits.
Mean age in both treatment groups was 67 ± 6 years. Despite risk matching, EVAR patients had more comorbidity including obesity, previous CAD, steroid use, and bleeding disorders/chronic anticoagulation.    


 Safer Across the Board   

EVAR was associated with a threefold lower rate of 30-day mortality as well as reduced incidence of major complications and perioperative morbidity across several organ systems (table 1). 

 
Table 1. Complications and Perioperative Morbidity: EVAR vs. Open Surgery

 

EVAR 
(n = 4,068) 

Open Surgery

(n = 1,459) 

P Value

30-Day Mortality

0.5%

1.5%

.001

Sepsis

0.7%

3.2%

< .001

Unplanned Reintubation

0.1%

5.4%

< .001

Pneumonia

0.8%

6.1%

< .001

Acute Renal Failure

0.4%

2.7%

< .001

Venous Thromboembolism

0.3%

1.1%

.001

Cardiac Arrest

0.2%

0.8%

< .001

Neurologic Deficits

0.2%

0.5%

.032

Urinary Tract Infections

1.2%

2.0%

.02   



In addition, median length of stay was shorter for the EVAR group compared with the surgical group (1 day vs 6 days; P < .001). EVAR patients also had a lower rate of reoperation within 30 days (3.7% vs 6.0%; P < .001).

A Controversy Settled?

“Whereas the benefit of EVAR in high-risk patients is self-evident, the optimal management of patients with AAA who are at ‘low risk’ for [open surgical repair has] remained controversial,” the authors observe.

“The improved perioperative outcomes with EVAR in the low-risk patient population seen here need to be balanced with the long-term risk for reintervention and durability of the repair,” Dr. Siracuse and colleagues continue, adding that it is no longer appropriate to assume that perioperative risk is equal between EVAR and surgery for the lowest-risk male patients. And understanding short-term outcomes “has a critical role in clinical decision making,” they say.

In a telephone interview with TCTMD, Dr. Siracuse noted that EVAR reinterventions, like the initial procedure, often carry few complications. Moreover, he added, as endovascular devices improve over time, the need for reintervention may diminish. 

Asked whether the current findings may lead low-risk patients to opt for EVAR without due consideration of its limited durability and longer-term mortality risk, Dr. Siracuse replied, “I think you have to educate them that this is not just a quick fix and give them all the facts.” The choice of treatment must be tailored to individual patients, he added.

Crucial Issue Unaddressed  

In an email with TCTMD, Frank A. Lederle, MD, of the Veterans Affairs Medical Center (Minneapolis, MN), observed that virtually all studies, including randomized trials, have reported lower perioperative mortality for EVAR compared with open repair. “The issue has been the increased late deaths after EVAR, which cause the mortality benefit to disappear in a few years, and the greater number of late ruptures after EVAR,” he said.    

“The study sets out to address the belief that ‘the favorable durability of [open surgical repair] overshadows any short-term benefits of EVAR’ but then reports only on the short-term benefit,” Dr. Lederle noted, adding that “the 30-day mortality after EVAR was lower in the OVER trial than in this study, but there was no long-term advantage.” 

 


Source: 
Siracuse JJ, Gill HL, Graham AR, et al. Comparative safety of endovascular and open surgical repair of abdominal aortic aneurysms in low-risk male patients. J Vasc Surg. 2014;Epub ahead of print.

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EVAR Safer Than Surgery Even in Low-Risk Men

Disclosures
  • Drs. Siracuse and Lederle report no relevant conflicts of interest.

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