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Original Investigation | Pacific Coast Surgical Association

Survival After Endovascular vs Open Aortic Aneurysm Repairs

David C. Chang, PhD, MPH, MBA1; Ralitza P. Parina, MPH2; Samuel E. Wilson, MD3
[+] Author Affiliations
1Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston
2School of Medicine, University of California–San Diego
3Department of Surgery, University of California–Irvine, Orange
JAMA Surg. 2015;150(12):1160-1166. doi:10.1001/jamasurg.2015.2644.
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Importance  To our knowledge, long-term outcomes of open and endovascular (EVAR) repairs of abdominal aortic aneurysms (AAAs) have not been studied on a population level outside a controlled trial setting.

Objective  To determine long-term outcomes of EVAR vs open repair on a population level.

Design, Setting, and Participants  Analysis of the longitudinally linked California Office of Statewide Health Planning and Development inpatient database from 2001 to 2009. Median follow-up was 3.3 years.

Exposures  Endovascular vs open repairs.

Main Outcomes and Measures  Mortality and complications at 30 days, as well as long-term mortality and complications up to 9 years.

Results  In this observational study, a total of 23 670 patients were studied, with 52% receiving EVAR. Endovascular repair was associated with improved 30-day outcomes (all-cause mortality, readmission, surgical site infection, pneumonia, and sepsis), as well as significantly improved survival until 3 years postoperatively. After 3 years, mortality was higher for patients who underwent an EVAR repair. No significant difference in long-term mortality was observed for the entire cohort on adjusted analysis (hazard ratio, 0.99; 95% CI, 0.94-1.04; P = .64). Endovascular repair was found to be associated with a significantly higher rate of reinterventions and AAA late ruptures.

Conclusions and Relevance  The survival advantage for EVAR repair in a statewide population is maintained for 3 years. After 3 years, EVAR repair was associated with higher mortality; however, these mortality differences did not reach statistical significance over the entire study period. Reintervention and late AAA rupture rates are higher after EVAR repair.

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Figure 1.
Mortality Over Time

Unadjusted Kaplan-Meier analysis of mortality by repair type. EVAR indicates endovascular. The shaded areas indicate 95% CIs.

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Figure 2.
Readmissions Over Time

Unadjusted Kaplan-Meier analysis of readmission rates by repair type. EVAR indicates endovascular. The shaded areas indicate 95% CIs.

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Figure 3.
Reoperation and Rupture Over Time

Unadjusted Kaplan-Meier analysis of long-term outcomes by repair type. AAA indicates abdominal aortic aneurysm; EVAR, endovascular. The shaded areas indicate 95% CIs.

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Figure 4.
Mortality and Repeat Repair Over Time by Age

Unadjusted Kaplan-Meier Analysis of long-term outcomes by age and repair type. EVAR indicates endovascular. The shaded areas indicate 95% CIs.

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