Long-Term Outcomes of Endovascular vs. Open Aneurysm Repair in the VQI-VISION Database
Kevin Yei, Nadin Elsayed, Asma Mathlouthi, Mahmoud Malas
University of California San Diego, La Jolla, CA
INTRODUCTION: Endovascular aneurysm repair (EVAR) has become the dominant modality of treatment for abdominal aortic aneurysms (AAA) and is associated with a significant reduction in perioperative mortality and morbidity compared to open aneurysm repair (OAR). However, prior studies have demonstrated that the benefits of EVAR over OAR decrease over time due to an increase in the risk of late aneurysm rupture and reinterventions in patients undergoing EVAR. We aimed to compare long-term outcomes of EVAR vs. OAR using the Vascular Quality Initiative (VQI) Vascular Implant Surveillance and Interventional Outcomes Network (VISION) database.
METHODS: We included all cases in the EVAR and OAR data from VQI-VISION 2003-2016. Patients undergoing emergent repair for ruptured AAA were excluded. Patients were divided based on procedure type (EVAR or OAR). The primary long-term outcome of interest was 1-year, 5-year, and 10-year all-cause mortality. Secondary outcomes included 1-year, 5-year, and 10-year aneurysm rupture and reintervention. Kaplan-Meier analysis, log-rank tests, and Cox-regression were utilized to compare outcomes. Variables adjusted for included: age, gender, ethnicity, bmi, smoking, diabetes, CAD, hypertension, CHF, COPD, dialysis, CKD, prior CABG/PCI, prior lower limb revascularization, prior aneurysm repair, max AAA diameter, preoperative medications, and symptomatic status.
RESULTS: A total of 26,863 AAA repairs were performed with 22,080 (82.2%) EVAR and 4,783 (17.8%) OAR. Patients undergoing OAR were more likely to have be symptomatic and have larger AAA diameter. On adjusted analysis, OAR had significantly higher mortality at 1 year (aHR 1.23, 95%CI 1.09-1.40, p<0.001) and 10 years (aHR 1.19, 95%CI 1.08-1.31, p<0.001), but not at 5 years (aHR 1.07, 95%CI 0.98-1.17, p=0.138). OAR had significantly lower rates of rupture and reintervention at 1-year (rupture, aHR 0.72, 95%CI 0.52-0.99, p=0.041; reintervention, aHR 0.42 95%CI 0.33-0.53, p<0.001), 5-years (rupture, aHR 0.64, 95%CI 0.50-0.83, p<0.001; reintervention, aHR 0.38, 95%CI 0.33-0.45, p<0.001), and 10-years (rupture, aHR 0.66, 95%CI 0.54-0.86, p<0.001; reintervention, aHR 0.41, 95%CI 0.35-0.48, p<0.001).
CONCLUSIONS: After adjusting for potential confounders, EVAR demonstrated mortality benefit compared to OAR at 10-years of follow-up. However, EVAR also demonstrated substantially increased rates of rupture and reintervention. This study emphasizes the importance of long-term follow up with careful surveillance of EVAR patients.
| EVAR, % Freedom(n=22080, 82.2%) | OAR, % Freedom(n=4783,17.8%) | Log-Rank | aHR (OAR:EVAR) | p-value | |||||
| 1-Year | Mortality | 92.21% | 90.47% | <0.001 | 1.23 (1.09-1.40) | <0.001 | |||
| Rupture | 97.89% | 98.23% | 0.16 | 0.72 (0.52-0.99) | 0.041 | ||||
| Reintervention | 94.81% | 97.34% | <0.001 | 0.42 (0.33-0.53) | <0.001 | ||||
| 5-Year | Mortality | 79.86% | 79.49% | 0.47 | 1.07 (0.98-1.17) | 0.138 | |||
| Rupture | 96.24% | 97.03% | 0.0124 | 0.64 (0.50-0.83) | <0.001 | ||||
| Reintervention | 89.81% | 95.09% | <0.001 | 0.38 (0.33-0.45) | <0.001 | ||||
| 10-Year | Mortality | 70.68% | 61.94% | <0.001 | 1.19 (1.08-1.31) | <0.001 | |||
| Rupture | 97.03% | 96.40% | 0.0122 | 0.66 (0.54-0.86) | 0.001 | ||||
| Reintervention | 88.33% | 92.59% | <0.001 | 0.41 (0.35-0.48 | <0.001 |
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