Comparison of Long-term Survival After Open vs Endovascular Repair of Intact Abdominal Aortic Aneurysm Among Medicare Beneficiaries

Abstract

Conclusion:In Medicare beneficiaries, repair of isolated, intact abdominal aortic aneurysms (AAA) by endovascular means is associated with a lower risk of all-cause mortality and AAA-related mortality than repair using open techniques.Summary: Randomized clinical trials (RCTs) have failed to demonstrate a long-term survival advantage of endovascular repair vs open repair of AAA. Furthermore, a previous study of Medicare beneficiaries undergoing AAA repair between 2001 and 2004 also failed to demonstrate a survival advantage of endovascular repair over open repair beyond 3 years of follow-up (Schemerhorn ML et al, N Engl J Med 2008;358:464-74). It is possible current endovascular devices may provide improved overall results of endovascular repair than those available for analysis of endovascular vs open AAA repair in the previous study of Medicare beneficiaries. The authors, therefore, decided to compare overall and AAA-specific mortality, readmission, and reintervention after endovascular vs open repair of nonruptured AAAs in Medicare beneficiary patients using a database from 2003 to 2007. This was a retrospective analysis of patients aged Ն65 years in the Medicare standard analytic file, 2003 to 2007, who underwent isolated repair of an intact AAA. The national death index was used to determine cause of death. Primary outcome was all-cause mortality. Secondary outcomes were AAA-related mortality, hospital length of stay, 1-year readmission, repeat AAA repair, incisional hernia repair, and lower extremity amputation. The Medicare standard analytic files contained data from a 5% example of Medicare inpatient discharges. The study included 4029 patients; of these, 703 underwent open repair and 3826 underwent endovascular repair. Mean and median follow-up times were 2.6 (SD, 1.5) and 2.5 (interquartile range, 2.4) years, respectively. After adjusting for emergency admission, age, calendar year, sex, race, and comorbidities, there was a higher risk of both all-cause mortality (hazard ratio, 1.24; 95% confidence interval [CI], 1.05-1.47; P ϭ .01) and AAA-related mortality after open vs endovascular repair (hazard ratio, 4.37l; 95% CI, 2.51-7.66; P Ͻ .001). Adjusted hospital length of stay averaged 6.5 days (95% CI, 6.0-7.0 days; P Ͻ .001) longer after open repair (mean, 10.4 days) compared with endovascular repair (mean, 3.6 days). Need for incisional hernia repair was higher after open AAA (P Ͻ .001). The 1-year readmission rates, repeat AAA repair, and lower extremity amputation did not differ by repair type.Comment: The data presented here do not demonstrate inferiority of endovascular vs open AAA repair. However, there are really too many deficiencies in the data to justify a conclusion that the data demonstrate superiority of endovascular vs open repair of AAAs. First, follow-up is relatively short and the number of patients analyzed quite small compared with the number potentially available for analysis. In addition, the Medicare database does not contain information about aneurysm configuration and other anato...

Adding an endovascular aortic surgery program to a rural regional medical centre

“…For our study, the mean length of stay in hospital for endovascular and open repairs was also similar to that of other studies. [7][8][9][10][11] The rate of morbidities and endoleaks in our study was similar to results of these other trials.…”

“…The results of AAA repair by both endovascular and open means at BMC are similar to results reported in major studies and reviews. [7][8][9][10][11] The patient population for our study was similar to that in these trials. These studies report 30-day mortality of 0.5%-1.2% for endovascular repair and 3.0%-4.8% for open repair.…”

“…Randomized trials have demonstrated the safety of EVAR versus open repairs with lower early mortality, but some of the data remain controversial as to overall superiority in patients younger than 65 years. 8,11 Our patient selection (average age 71.7 yr) was in keeping with this as well as the 2009 Society of Vascular Surgery guidelines. 20 More than half the abdominal aneurysm repairs in the United States are currently treated by endovascular means.…”

“…Despite questions about longterm benefit and potentially higher up-front costs, these procedures are more appealing because they have significantly lower 30-day morbidity and mortality. [7][8][9][10][11] Adding an endovascular aortic repair program to an existing surgical product line may not be possible because there could be too few vascular cases to attract a vascular surgeon. 12,13 In such instances, local general surgeons often have provided open vascular surgery services, including abdominal aortic aneurysm repair.…”

Long-term survival after endovascular and open repair of unruptured abdominal aortic aneurysm

“…The long‐term outcomes of elective EVAR and open repair have also been examined in various population‐based cohort studies. These benefited from having less restrictive eligibility criteria compared with the trials, which in general had patients with fewer co‐morbidities than the general AAA population, but they produced inconsistent results.…”