NAPLES, FLA. – Endovascular aneurysm repair is associated with better long-term survival compared with open abdominal aortic aneurysm surgery, although re-intervention rates for the two techniques were similar in a single-center, retrospective study.
In a registry of 1,066 endovascular aneurysm repair (EVAR) and 920 open abdominal aortic aneurysm (AAA) procedures, all-cause mortality in the first 100 months was 25% following EVAR and 39% after open repair. The mortality disparity was significant, even though the EVAR patients tended to be older and had more comorbidities, such as hypertension or diabetes, Dr. Brenton E. Quinney said at the annual meeting of the Southern Association for Vascular Surgery.
One-year mortality was 16% in the EVAR group and 28% in the open-repair group. At 5 years, mortality rose to 36% and 48%, respectively. "EVAR had better immediate, mid-term, and long-term survival out to 9 years," said Dr. Quinney, a vascular surgery fellow at the University of Alabama at Birmingham.
To compare durability of EVAR vs. open AAA, they examined EVAR cases performed from 1999 to 2009 and open repairs from 1985 to 2009 at the University of Alabama.
Secondary interventions were vascular (aortic graft-related or remote procedures, such as carotid surgery) or nonvascular (incisional or gastrointestinal surgery). "Patients required more secondary vascular procedures after EVAR," Dr. Quinney said. In contrast, "patients required more nonvascular procedures after open AAA repair."
Dr. Quinney and his associates found 12.3% of EVAR versus 5.1% of open surgery cases required graft-related subsequent procedures. "However, when we add GI complications and laparotomy complications, both groups are virtually identical with overall re-intervention rates," Dr. Quinney said. Specifically, 21.9% of the EVAR and 21.1% of the open cases required a re-intervention during the 290-month follow-up (mean, 27 months).
In the EVAR group, the graft-related secondary interventions were mostly minimally invasive transfemoral procedures (131 cases, or 56%). Subsequent nonaortic vascular procedures included 63 cases of infra-inguinal bypass, 13 thoracic aortic aneurysms (TAAs), and 4 gastrointestinal bleed repairs, Dr. Quinney said.
In the open-surgery group, graft-related re-interventions were mostly secondary aneurysm repairs (23 cases). There were also 34 infra-inguinal bypass procedures and 22 TAA repairs in this group. All 97 nonvascular secondary surgeries in the study occurred in patients who initially underwent open surgery.
"What would be your preferred approach to a healthy 54-year-old male patient when this man wants you to make the decision?" asked study discussant Dr. Karthikeshwar Kasirajan, director of clinical research, division of vascular surgery, at Emory University in Atlanta.
"In a 54-year-old with suitable anatomy for AAA, we would probably recommend an EVAR," Dr. Quinney replied.
Potential limitations include the retrospective study design based on nonvascular procedures from medical records and patient reports. Also, the registry at the University of Alabama tracks only procedures, not patients, so "one patient could have had multiple procedures," Dr. Quinney said.
These current findings demonstrating a long-term survival benefit with EVAR differ from results of the Dutch Randomized Endovascular Aneurysm Management (DREAM) trial (N. Engl. J. Med. 2005;352:2398-405). EVAR showed an early postoperative survival advantage versus open repair in the DREAM trial, but "mortality equalized at 1 year," Dr. Quinney said.
Secondary intervention rates in this patient population vary, partly because of different follow-up times, Dr. Quinney said, noting that a comparison of 444 EVAR and 437 open-repair outcomes during a mean 1.8-year follow-up found essentially equivalent rates of secondary interventions (JAMA 2009;302:1535-42). Another study showed a 9.8% re-intervention rate among 543 EVAR cases, compared with 5.8% of 539 open repairs over 4 years (Lancet 2004;364:843-8).
Dr. Quinney said that he had no relevant disclosures. Dr. Kasirajan receives research support from W.L. Gore and Medtronic.