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January 31, 2025
Study Examines Nationwide Trends in Aortic Aneurysm Admissions and Repairs
January 31, 2025—In a multicenter, retrospective review of patients admitted with intact and ruptured abdominal aortic aneurysms (AAAs), thoracic aortic aneurysms (TAAs), and thoracoabdominal aortic aneurysms (TAAAs), Conroy et al found that use of endovascular and complex endovascular techniques increased over the past 2 decades, surpassing open repair, and both intact AAA repairs and ruptured AAA admissions significantly decreased. Results were published online in Journal of Vascular Surgery.1
KEY FINDINGS
- Over the past 2 decades, use of endovascular techniques for both intact and ruptured aortic aneurysms increased.
- EVAR and complex EVAR have surpassed open repair for all intact and ruptured AAAs and TAAAs.
- Mortality rates after EVAR for AAAs have decreased, and mortality rates after complex EVAR have remained stable.
- Decreases were seen in ruptured AAA presentations, turndown rates for ruptured TAAA and TAA, and mortality after ruptured aortic aneurysms.
Investigators used diagnosis codes (ICD-9 and ICD-10) within the National Inpatient Sample to identify patients who were admitted for intact and ruptured AAAs, TAAs, and TAAAs between 2004 and 2019 and examined use of open repair, endovascular aneurysm repair (EVAR), or complex EVAR (ie, branched, fenestrated, chimney/snorkel, physician-modified endografts) and subsequent in-hospital mortality. Turndown rates were collected for those presenting with ruptured aneurysms. A subanalysis of patients with TAA who presented after 2017 was performed, when the ICD-10 started to distinguish between ascending and arch TAA and descending TAA.
For AAA, 717,570 patients were identified (87% intact repairs, 13% ruptured admissions). The turndown rate for ruptured AAAs remained stable over the study period. Intact AAA repairs, ruptured AAA admissions, and ruptured AAA repairs significantly decreased (all P < .01). Open repair for intact AAA (55% to 11%) and ruptured AAA (90% to 32%) decreased, whereas use of EVAR increased (intact AAAs, 45% to 66%; ruptured AAAs, 10% to 55%). Use of complex EVAR increased significantly for both intact (0% to 23%; P < .01) and ruptured AAA repairs (0% to 14%; P < .01) during the study period.
From 2004 to 2019, for intact AAAs, there was a 29% decrease in mortality after EVAR (0.73% to 0.52%; P < .01) and an increase of 16% after open repair (4.4% to 5.1%; P < .01).
For TAAAs, 27,443 patients were identified (80% intact, 20% ruptured). Over the study period, intact TAAA repairs increased, ruptured TAAA admissions decreased, and the turndown rate for ruptured TAAA decreased. Open repair for both intact and ruptured TAAA decreased from 96% and 97%, respectively, in 2004 to 28% and 58%, respectively, in 2019 (P < .01 and P = .01, respectively). Use of complex EVAR for both intact and ruptured TAAA increased from 3.8% and 2.6%, respectively, in 2004 to 72% and 42%, respectively, in 2019 (P < .01 and P = .01, respectively).
From 2004 to 2019, mortality remained stable after both open repair and complex EVAR of intact and ruptured TAAAs (open repair: P = .99 and P = .95; complex EVAR: P = .74 and P = .56).
For TAAs, 141,651 patients were identified (90% intact, 10% ruptured). Both intact and ruptured TAA repairs increased during the study period, and the turndown rate decreased from 71% in 2004 to 48% in 2019 (P < .01). Use of open repair for intact TAA remained stable during the study period; however, a significant decrease was seen for ruptured TAAs from 100% in 2004 to 29% in 2019 (P < .01).
Mortality after open repair for intact TAA decreased, whereas it remained stable for ruptured TAA. Mortality after thoracic endovascular aortic repair (TEVAR) of both intact and ruptured TAA remained stable over time.
In the subanalysis of TAA patients, TEVAR use was stable for all intact TAAs, increased for ruptured ascending or arch TAA, and remained stable for descending TAA. Mortality rates were unique to approach and thoracic aortic location: Increased mortality was seen for open repair of both intact and ruptured descending TAA, decreased mortality was seen for TEVAR of both intact and ruptured descending TAA, and decreased mortality was seen for both open repair or TEVAR of ascending or arch TAA.
As noted by the investigators, study limitations mainly stem from the use of the National Inpatient Sample database, including potential for coding and documentation errors, selection bias, and inability to detect readmissions, reinterventions, or late survival. The calculated turndown rates may also be overestimated, as patients may be transferred to other hospitals for management.
The investigators also note that these results show a discrepancy in in-hospital mortality regardless of approach, whether simple or complex, and this may encourage hospitals and practitioners to further analyze how they manage these patients. With the increasing adoption of endovascular interventions for aortic aneurysm patients, more studies are needed to compare long-term outcomes, concluded the investigators.
1. Conroy PD, Rastogi V, Yadavalli SD, et al. The rise of endovascular repair for abdominal, thoracoabdominal, and thoracic aortic aneurysms. J Vasc Surg. 2025;81:14-28. doi: 10.1016/j.jvs.2024.06.165
ENDOVASCULAR TODAY ASKS…
Study investigator Marc L. Schermerhorn, MD, with Beth Israel Deaconess Medical Center in Boston, Massachusetts, expanded on the implications of these findings and what’s next for aortic aneurysm management.
This study included the first subanalysis of TAA patients since the 2017 ICD-10 revision distinguishing TAA by location. How do these data fit into the existing TAA landscape?
Until this change, we had no way of knowing how often TEVAR was being used for descending thoracic, ascending thoracic or arch disease. As we expected, the vast majority of ascending and arch cases are still being performed open, but we’re now able to see how much TEVAR has replaced open surgery for the descending thoracic aorta as we all expected. This will also allow us to track trends in the future of ascending and arch TEVAR as technology and experience improve over time.
With stable mortality rates for AAA and TAAA despite increased use of complex EVAR, findings suggest complex EVAR might be useful in a larger population of patients. What real-world trends do you think are driving the observed outcomes with complex EVAR?
I would agree. The data are supportive of expanded use of complex EVAR; however, we really need long-term durability data to be sure this is appropriate. I think the introduction of a commercial fenestrated device got things started, and then I’m guessing that physicians with the skillset for complex EVAR began using physician-modified endografts for more extensive disease (as we have seen with Vascular Quality Initiative data), and the initial results with this seem to be positive, which likely is driving the steady rise in utilization. However, again, it’s important that we track long-term outcomes to be sure we’re offering the best treatment.
The findings inferred that a decrease in intact AAA repairs and no increase in ruptured AAAs might reflect reduction in overall prevalence/progression of AAA in the United States. How should this potential trend be further explored, and what are its implications?
Initially, after the introduction of EVAR, we saw a significant decrease in AAA-related deaths as more older and frail patients were candidates for EVAR but not open surgery. So, there was a steady rate of repair overall but a dramatic increase in older patients and a dramatic decrease in ruptures in the older patients. Simultaneously, we see a decrease in smoking over the past several decades, which is leading to a decrease in the incidence of AAA. I think the same thing is occurring for complex EVAR, where more patients are now candidates for intervention, and thus we’re seeing a larger decrease in ruptures than we would expect from the decreasing prevalence alone.
What should clinicians take away from this study in terms of clinical practice?
Although the study is primarily epidemiological documenting changing management trends, I do think the study is supportive of the increasing use of endovascular aortic repair in the abdominal thoracoabdominal, and descending thoracic aorta, with the caveat that we need long-term data.
How do the findings from this study inform future research on aortic aneurysm management?
I think one of the primary takeaways for future research is the study of long-term outcomes of these complex interventions for complex aortic disease. In addition, to me it shows that we need more endografts to manage the increasing complexity of endoaortic intervention, which would allow more treatment of complicated AAA and TAAA as well as arch and ascending disease.
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