SCOTTSDALE, ARIZ. – Repairing a first abdominal aortic aneurysm by endovascular techniques instead of open surgery improves survival if the patient eventually needs a second aortic repair of either kind, a retrospective study of 149 patients suggests.
Among 2,256 abdominal aneurysm repairs performed at one institution in 1986-2011, 149 patients (7%) required secondary aortic procedures – EVAR (endovascular aneurysm repair) or TEVAR (transthoracic endovascular aneurysm repair) in 77 patients, and an open surgical repair after initial EVAR/TEVAR in 72 patients.
For the 77 patients who first underwent EVAR or TEVAR (referred to jointly as EVAR in the study), 10 of 61 patients died within 1 year of a second EVAR (16%) and 2 of 16 patients died within 1 year of an open repair after the initial EVAR (13%).
Sherry Boschert
Dr. Dean J. Yamaguchi
Among the 72 patients who first underwent open surgical aneurysm repair, 10 of 36 patients died within 1 year of EVAR after an initial open repair (28%), and 8 of 36 patients died within 1 year of a second open repair (22%), Dr. Dean J. Yamaguchi and his associates reported at the annual meeting of the Southern Association for Vascular Surgery.
"The initial operative approach to abdominal aortic aneurysm influences mortality in patients who require secondary repair," said Dr. Yamaguchi of the University of Alabama at Birmingham. "Survival is greatest for patients who undergo initial EVAR, even if a secondary open repair is required."
Previous studies have suggested that 12%-20% of patients undergoing EVAR eventually require secondary interventions because of stent graft migration, fracture, or aneurysmal disease progression (N. Engl. J. Med. 2005;352:2398-405; Lancet 2005;365:2179-86). Although a second EVAR may be possible in most of these patients, it hasn’t been clear how this might affect mortality, he said.
A review of the University of Alabama at Birmingham’s experience with EVAR and open aortic aneurysm repair found that patients undergoing EVAR had better long-term survival than did patients treated by open repair, but the EVAR group required more secondary procedures related to the aortic graft. Patients in the open-repair group required more nonvascular interventions subsequently (J. Vasc. Surg. 2011;54:1592-8).
The current study of patients undergoing secondary aortic repairs excluded secondary interventions involving the ascending aorta or iliac arteries.
Patients who had an initial open repair were significantly younger than patients who initially underwent EVAR, and the time between the primary and secondary interventions was significantly longer after initial open repairs than after initial EVAR.
The mean age at the time of the first intervention was 69 years for patients who underwent two EVARs, 68 years in the initial EVAR and secondary open-repair group, 60 years in the initial open-repair and secondary EVAR group, and 63 years for patients who underwent two open repairs. The interval between the first and second intervention was 3 years in the EVAR/open group, 2 years in the EVAR/EVAR group, 13 years in the open/EVAR group, and 7 years in the open/open group.
In a multivariate analysis that adjusted for the effects of confounding factors, the risk of dying within 1 year of a secondary intervention was three times higher in the open/EVAR group, compared with the EVAR/EVAR group, a statistically significant difference. The 1-year death rates after secondary intervention were higher in the open/open group and lower in the EVAR/open group, compared with the EVAR/EVAR group, but these differences were not statistically significant, Dr. Yamaguchi reported.
The study controlled for the effects of age at the time of the secondary aortic procedure; sex; race; duration between first and second aortic procedures; coronary artery disease; hypertension; hyperlipidemia; stroke; obesity; and diabetes.
The study is limited by its retrospective nature and by drawing data from a single institution. Also, the study did not include anatomical data, and EVAR may be chosen for intervention based on anatomy, not necessarily by medical condition, he said.
The patient groups did not differ significantly in age at the time of secondary intervention; sex; the percentage of nonwhite patients or smokers; or in the proportions of patients with a history of coronary artery disease, stroke, diabetes, hypertension, or hyperlipidemia.
Dr. Yamaguchi reported having no financial disclosures.