EVAR Shows Superiority to Open AAA Repair for Long-Term Survival in Medicare Patients

 

April 17, 2012—In the Journal of the American Medical Association, Rubie Sue Jackson, MD, et al published findings from a comparison of long-term survival after open surgical repair versus endovascular repair (EVAR) of intact abdominal aortic aneurysms (AAAs) among Medicare beneficiaries (2012;307:1621–1628).

A retrospective analysis looked at patients aged 65 years or older in the Medicare Standard Analytic File who underwent isolated repair of intact AAA from 2003 to 2007. The investigators concluded that use of open repair, compared with EVAR, was associated with a higher risk of all-cause mortality and AAA-related mortality.

As detailed in the Journal of the American Medical Association, the analysis of 4,529 patients included 703 patients who had undergone open repair and 3,826 patients who had undergone EVAR. Mean and median follow-up times were 2.6 (SD, 1.5) and 2.5 (interquartile range, 2.4) years, respectively. The primary outcome of the study 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. Cause of death was determined from the National Death Index.

The investigators reported that an unadjusted analysis showed that in open repair versus EVAR both all-cause mortality (173 vs 752; 89 vs 76/1,000 person-years; P = .04) and AAA-specific mortality (22 vs 28; 11.3 vs 2.8/1,000 person-years; P < .001) were higher. After adjusting for emergency admission, age, calendar year, sex, race, and comorbidities, there was a higher risk of both all-cause mortality (hazard ratio [HR], 1.24; 95% confidence interval [CI], 1.05–1.47; P = .01) and AAA-related mortality (HR, 4.37; 95% CI, 2.51–7.66; P < .001) after open repair versus EVAR.

The adjusted hospital length of stay was, on average, 6.5 days (95% CI, 6–7 days; P < .001) longer after open repair (mean, 10.4 days), compared with EVAR (mean, 3.6 days). The incidence of incisional hernia repair was higher after open AAA repair (19 vs 23; 12 vs 3 per 1,000 person-years; adjusted HR, 4.45; 95% CI, 2.37–8.34; P < .001), whereas the incidence of 1-year readmission (188 vs 1,070; 274 vs 376/1,000 person-years; adjusted HR, 0.96; 95% CI, 0.85–1.09; P = .52), repeat AAA repair (15 vs 93; 9.7 vs 12.3/1,000 person-years; adjusted HR, 0.8; 95% CI, 0.46–1.38; P = .42), and lower extremity amputation (3 vs 25; 1.9 vs 3.3/1,000 person-years; adjusted HR, 0.55; 95% CI, 0.16–1.86; P = .34) did not differ by repair type, according to the investigators.

 

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