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August 24, 2020

EVAR Compared With Open Repair for Ruptured AAA in Propensity-Matched Analysis of VQI Data

August 24, 2020—The Society for Vascular Surgery (SVS) announced that a large retrospective review of prospectively collected data from the Vascular Quality Initiative (VQI) suggests a more aggressive endovascular approach is warranted for patients presenting with ruptured abdominal aortic aneurysm (rAAA). Linda J. Wang, MD, et al published the study in Journal of Vascular Surgery (2020;72:498-507).

According to SVS, patients with rAAAs continue to present a significant challenge to vascular surgeons. Data included in this large study suggest that endovascular therapy applied to anatomically suitable patients appears to be the procedure of choice in terms of reducing early morbidity and mortality.

The study was led by senior investigator Mahmoud Malas, MD. “The literature remains mixed on whether endovascular aortic aneurysm repair (EVAR) provides a survival benefit over open surgical repair (OSR) of rAAA,” commented Dr. Malas in the SVS announcement. He continued, “Observational studies have suggested that EVAR may be associated with lower 30-day mortality, but many of these studies have inherent flaws introducing selection bias. Conversely, the three randomized controlled trials studying this subject have failed to demonstrate a survival benefit of one approach over the other.”

According to SVS, the investigators used a propensity-matched analysis of VQI data to assess contemporary, real-world treatment of rAAAs. The review included 4,929 repairs performed between 2003 and 2018 (EVAR, n = 2,749; OSR, n = 2,180). Patient characteristics included mean age of 73 ± 10 years; 22% female; AAA size of 71 mm in EVAR patients versus 77 mm in OSR patients (P < .001); and hypotension in 32% of EVAR patients versus 41% in OSR patients (P < .001).

The investigators propensity-matched 724 patients from each group and observed the following in EVAR-treated versus OSR-treated patients:

  • 30-day mortality of 18% versus 32% (P < .001)
  • Major morbidity of 35% versus 68% (P < .001)

Predictors for 30-day mortality included OSR (odds ratio [OR], 2.03); age > 60 years (OR, 2.23); female sex (OR, 1.39); obesity (OR, 1.41); and hypotension (OR, 2.04).

Dr. Malas stated, “This is one of the largest studies examining the effect of operative approach on outcomes in patients presenting with rAAA. Clear short-term and midterm survival benefits of EVAR over OSR were demonstrated. For institutions that elect to offer rAAA repair, the morbidity and mortality benefits presented highlight the importance of dedicating resources to providing endovascular treatment options. Although delays can occur in obtaining axial imaging, more than half of rAAA patients have anatomy suitable for EVAR.”

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