Causes of late mortality after endovascular and open surgical repair of infrarenal abdominal aortic aneurysms

Abstract

Introduction Several reports suggest unexpectedly high rates of late abdominal aortic aneurysm (AAA) rupture occur after endovascular AAA repair (EVAR). However, a population-based study examining causes of late death after EVAR vs open surgical repair has not been performed. Methods We performed a retrospective cohort study of patients undergoing infrarenal AAA repair using information from the Medicare inpatient hospital discharge records (MedPAR files), physician claim files (Part B files, 20% sample), and Medicare Denominator Files for the years 2001 to 2004. Using the Social Security Death Index, we identified all “late” deaths, defined as deaths occurring >30 days and after hospital discharge. We used the National Death Index to identify cause of death information; in particular, those deaths that were likely caused by late rupture. We compared causes of late death and survival between EVAR and open repair using Wilcoxon log-rank and rank-sum tests. Results Between 2001 and 2004, 13,971 patients underwent AAA repair (6119 EVAR, 7852 open repair). After a mean follow-up of 1.6 years in the EVAR cohort and 1.9 years in the open cohort, mortality rates were similar across repair type (15.4% EVAR, 15.9% open repair), with an adjusted odds ratio for death after open repair of 0.98 (95% confidence interval, 0.90–1.07). Of the 2194 documented deaths, 523 occurred before discharge or ≤30 days, and 1671 occurred >30 days and after hospital discharge. Cause of death information for the 1671 late deaths was available from the National Death Index for 1515 (91%). The 15 most common codes for causes of late death were dominated by cardiac disease (atherosclerotic heart disease, acute myocardial infarction) and pulmonary disease (lung cancer, respiratory failure). Causes of late death with specific mention of aneurysm were identified in 37 patients (2.4% of all deaths), but this event was not more common in EVAR or open repair (15 [0.3%] in the EVAR group, 22 [0.3%], in the open repair group; P=.71). Conclusions Late deaths from aneurysm rupture after EVAR or open repair appear to be relatively infrequent and similarly distributed across procedure type. Our results emphasize that the effectiveness of EVAR is comparable to open AAA repair in preventing aneurysm-related death.

Long-term incidence of myocardial infarct, stroke, and mortality in patients operated on for abdominal aortic aneurysms

“…Previous studies have yielded similar rates of MI (10% to 40%) or stroke (5% to 15%) before AAA repair, just as this study confirms that AAA patients, in general, are at increased risk of death. [12][13][14][15] We found an annual rate of 2.0% for MI and 2.5% for stroke in patients without a previous occurrence of either event. This corresponds well with the rates found in the prospective, international Reduction of Atherothrombosis for Continued Health (REACH) registry study, 16 where 1722 patients (of 68,236 out-patients enrolled) with an established AAA diagnosis had a 1.8% annual rate of MI and a 1.9% annual rate of stroke.…”

Survival After Open Versus Endovascular Thoracic Aortic Aneurysm Repair in an Observational Study of the Medicare Population

“…However, in these trials, as well as large observational analyses 30 , the survival advantage gained by an endovascular approach consistently disappears within two years after surgery, and little difference in long-term survival is evident thereafter across procedures. Patients who experience late death following infrarenal AAA repair most commonly die from cardiopulmonary comorbidities unrelated to their aneurysm, and relatively few experience aneurysm-related death, in either open or endovascular repair 34 . In other words, in both randomized trials and in real-world practice, while EVAR is as effective in preventing aneurysm-related death as open repair, it does not result in prolonged improvement or detriment in survival.…”

Risk stratification for the development of respiratory adverse events following vascular surgery using the Society of Vascular Surgery's Vascular Quality Initiative

“…1–3 While a few studies that have focused on post-operative complications in vascular surgery patients specifically, these have been limited to single center studies; moreover these studies have only assessed the impact of respiratory failure on outcomes alone without developing a comprehensive risk model for the development of this morbid complication. 5, 19, 21, 25 …”