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Endovascular repair of ruptured abdominal aortic aneurysms does not reduce later mortality compared with open repair.
J Vasc Surg. 2016 Mar; 63(3):617-24.JV

Abstract

OBJECTIVE

Endovascular aneurysm repair (EVAR) of ruptured abdominal aortic aneurysms (RAAAs) reduces in-hospital mortality compared with open repair (OR), but it is unknown whether EVAR reduces long-term mortality. We hypothesized that EVAR of RAAA would independently reduce long-term mortality compared with OR.

METHODS

The Vascular Quality Initiative database (2003-2013) was used to determine Kaplan-Meier 1-year and 5-year mortality after EVAR and OR of RAAA. Multivariate analysis was performed to identify patient and operative characteristics associated with mortality at 1 year and 5 years after RAAA repair.

RESULTS

Among 590 patients who underwent EVAR and 692 patients who underwent OR of RAAA, the lower mortality seen in the hospital after EVAR (EVAR 23% vs OR 35%; P < .001) persisted at 1 year (EVAR 34% vs OR 42%; P = .001) and 5 years (EVAR 50% vs OR 58%; P = .003) after repair. After adjusting for patient and operative characteristics, EVAR did not independently reduce mortality at 1 year (hazard ratio [HR], 0.88; 95% confidence interval [CI], 0.7-1.1) or 5 years (HR, 0.95; 95% CI, 0.77-1.2) compared with OR. Dialysis dependence (HR, 3.9; 95% CI, 1.8-8.6), home oxygen use (HR, 1.9; 95% CI, 1.3-2.7), cardiac ejection fraction <50% (HR, 1.5; 95% CI, 1.03-2.1), female gender (HR, 1.3; 95% CI, 1.04-1.6), and age (HR, 1.06; 95% CI, 1.05-1.08 per 5 years) as well as cardiac arrest (HR, 3.4; 95% CI, 2.5-4.5), loss of consciousness (HR, 1.7; 95% CI, 1.3-2.2), and preoperative systolic blood pressure <90 mm Hg (HR, 1.4; 95% CI, 1.1-1.8) on admission predicted mortality at 1 year and 5 years after RAAA repair. Type I endoleak (HR, 2.2; 95% CI, 1.2-3.8) also predicted mortality at 1 year.

CONCLUSIONS

EVAR does not independently reduce long-term mortality compared with OR. Patient comorbidities and indices of shock on admission are the primary independent determinants of long-term mortality. However, the lower early mortality observed in the Vascular Quality Initiative for patients selected to undergo EVAR of RAAA compared with patients selected for OR is sustained over time, suggesting that EVAR for RAAA is beneficial in appropriate candidates. Better elucidation of the key selection factors, including aneurysm anatomy, is needed to best select patients for EVAR and OR to reduce long-term mortality.

Authors+Show Affiliations

Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester, Mass. Electronic address: wprobins3@gmail.com.Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester, Mass.Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester, Mass.Center for Outcomes Research, Department of Surgery, University of Massachusetts Medical School, Worcester, Mass.Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester, Mass.Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester, Mass.Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester, Mass.Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester, Mass.

Pub Type(s)

Comparative Study
Journal Article

Language

eng

PubMed ID

26916581

Citation

Robinson, William P., et al. "Endovascular Repair of Ruptured Abdominal Aortic Aneurysms Does Not Reduce Later Mortality Compared With Open Repair." Journal of Vascular Surgery, vol. 63, no. 3, 2016, pp. 617-24.
Robinson WP, Schanzer A, Aiello FA, et al. Endovascular repair of ruptured abdominal aortic aneurysms does not reduce later mortality compared with open repair. J Vasc Surg. 2016;63(3):617-24.
Robinson, W. P., Schanzer, A., Aiello, F. A., Flahive, J., Simons, J. P., Doucet, D. R., Arous, E., & Messina, L. M. (2016). Endovascular repair of ruptured abdominal aortic aneurysms does not reduce later mortality compared with open repair. Journal of Vascular Surgery, 63(3), 617-24. https://doi.org/10.1016/j.jvs.2015.09.057
Robinson WP, et al. Endovascular Repair of Ruptured Abdominal Aortic Aneurysms Does Not Reduce Later Mortality Compared With Open Repair. J Vasc Surg. 2016;63(3):617-24. PubMed PMID: 26916581.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Endovascular repair of ruptured abdominal aortic aneurysms does not reduce later mortality compared with open repair. AU - Robinson,William P, AU - Schanzer,Andres, AU - Aiello,Francesco A, AU - Flahive,Julie, AU - Simons,Jessica P, AU - Doucet,Danielle R, AU - Arous,Elias, AU - Messina,Louis M, PY - 2015/07/27/received PY - 2015/09/29/accepted PY - 2016/2/27/entrez PY - 2016/2/27/pubmed PY - 2016/7/7/medline SP - 617 EP - 24 JF - Journal of vascular surgery JO - J Vasc Surg VL - 63 IS - 3 N2 - OBJECTIVE: Endovascular aneurysm repair (EVAR) of ruptured abdominal aortic aneurysms (RAAAs) reduces in-hospital mortality compared with open repair (OR), but it is unknown whether EVAR reduces long-term mortality. We hypothesized that EVAR of RAAA would independently reduce long-term mortality compared with OR. METHODS: The Vascular Quality Initiative database (2003-2013) was used to determine Kaplan-Meier 1-year and 5-year mortality after EVAR and OR of RAAA. Multivariate analysis was performed to identify patient and operative characteristics associated with mortality at 1 year and 5 years after RAAA repair. RESULTS: Among 590 patients who underwent EVAR and 692 patients who underwent OR of RAAA, the lower mortality seen in the hospital after EVAR (EVAR 23% vs OR 35%; P < .001) persisted at 1 year (EVAR 34% vs OR 42%; P = .001) and 5 years (EVAR 50% vs OR 58%; P = .003) after repair. After adjusting for patient and operative characteristics, EVAR did not independently reduce mortality at 1 year (hazard ratio [HR], 0.88; 95% confidence interval [CI], 0.7-1.1) or 5 years (HR, 0.95; 95% CI, 0.77-1.2) compared with OR. Dialysis dependence (HR, 3.9; 95% CI, 1.8-8.6), home oxygen use (HR, 1.9; 95% CI, 1.3-2.7), cardiac ejection fraction <50% (HR, 1.5; 95% CI, 1.03-2.1), female gender (HR, 1.3; 95% CI, 1.04-1.6), and age (HR, 1.06; 95% CI, 1.05-1.08 per 5 years) as well as cardiac arrest (HR, 3.4; 95% CI, 2.5-4.5), loss of consciousness (HR, 1.7; 95% CI, 1.3-2.2), and preoperative systolic blood pressure <90 mm Hg (HR, 1.4; 95% CI, 1.1-1.8) on admission predicted mortality at 1 year and 5 years after RAAA repair. Type I endoleak (HR, 2.2; 95% CI, 1.2-3.8) also predicted mortality at 1 year. CONCLUSIONS: EVAR does not independently reduce long-term mortality compared with OR. Patient comorbidities and indices of shock on admission are the primary independent determinants of long-term mortality. However, the lower early mortality observed in the Vascular Quality Initiative for patients selected to undergo EVAR of RAAA compared with patients selected for OR is sustained over time, suggesting that EVAR for RAAA is beneficial in appropriate candidates. Better elucidation of the key selection factors, including aneurysm anatomy, is needed to best select patients for EVAR and OR to reduce long-term mortality. SN - 1097-6809 UR - https://www.unboundmedicine.com/medline/citation/26916581/Endovascular_repair_of_ruptured_abdominal_aortic_aneurysms_does_not_reduce_later_mortality_compared_with_open_repair_ DB - PRIME DP - Unbound Medicine ER -