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reduction in AAA-related mortality over 12–15years (OR 0.65), AAA-related ruptures over 12–15 years (OR, 0.62), and emergency surgical procedures over
4–15years (OR, 0.57). In contrast, no signicant association with all-cause mortality benet was seen at 12- to 15-year follow-up (relative risk 0.99). One-time
screening was associated with signicantly more procedures over 4–15years in the
invited group compared with the control group (OR, 1.44). One-time AAA screening in men 65years or older was associated with decreased AAA-related mortality
and rupture rates but was not associated with all-cause mortality benet. Higher
rates of elective surgery but no long-term differences in quality of life resulted from
screening. Overdiagnosis and overtreatment were not addressed in these trials but
may be important considerations given that most screen detected aneurysms
are small.
5.2.1.2 Screening forAAA inWomen
The aim of the Female Aneurysm screening STudy (FAST) was to determine the
uptake of screening and prevalence of AAA in a group of women deemed at high
risk of having an AAA using data that were readily available in UK primary care
records (white European ethnicity, current/ex-smokers and/or past history of coronary artery disease) [5]. Women aged 65–74years deemed at high risk of having an
AAA were invited to attend ultrasound screening (July 2016 to March 2019) for
AAA. Of the 5998 women invited for screening, 5200 (86.7%) attended their
screening appointment and 5190 (86.5%) had ultrasound screening. 15 AAAs larger
than 29mm were detected (prevalence 0.29%). Current smokers had the highest
prevalence (0.83%) but lowest attendance (75.2%). Three AAAs greater than 5.5cm
were identied and referred for consideration of surgical repair; one woman underwent repair. AAA prevalence in women with risk factors for AAA was lower than
0.35%, the prevalence threshold below which AAA screening for men is likely to be
ineffective. Screening women at high risk for AAA is unlikely to be either costeffective or clinically effective if those AAA detected have a low likelihood of
repair. A reduction in quality-of-life outcomes was identied after screening. This
suggests that a screening programme for AAA in women may cause harm. Health
services worldwide should exercise great caution before considering implementation of targeted screening of women for AAA.
5.2.1.3 Screening Effectiveness
The NHS Abdominal Aortic Aneurysm Screening Programme (NAAASP) has been
implemented since 2013. Men with a large aneurysm >54mm, either at rst screen
or during surveillance, are referred for intervention. The aim of a study presented by
Meecham [6] was to explore outcomes in these men and to see whether there was
any regional variation in treatment rates and type of repair. Some 3026 men were
referred for possible intervention. Some 2624 (87%) men had planned AAA repair,
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5 Abdominal Aortic Aneurysm (AAA)
with a peri-operative mortality of 1.3%. The mean age of this cohort was 67.6years
(range 64–92years), with a 30-day mortality of 0.4% after EVAR and 2.1% after
open repair. The method of repair remained consistent year on year, with roughly
equal numbers undergoing endovascular (50%) and open surgical repair (48%); 2%
unknown. However, there was a very wide range of EVAR use for screen detected
AAA (from 22 to 97%). Considering the high mortality rate of ruptured AAA
(rAAA), the authors described the English AAA screening programme as effective.
Using the National Inpatient Sample from 2004 to 2015, Dansey etal. [7] identied 65,125 admissions for ruptured AAAs and 461,191 repairs for intact AAAs.
The number of patients admitted for rAAA decreased signicantly over the observation period, from 6461in 2004 to 4848in 2015 (p<0.001). Of all patients with
rAAA undergoing repair, 14,012 (31%) underwent EVAR and 31,693 (69%) underwent open repair. Overall in-hospital mortality following repair of ruptured AAA
was 35%. However, there was a decrease in mortality over the study period, from
42% in 2004 to 28% in 2015 (P<.001). Of the 65,125 patients admitted with a
diagnosis of rupture, 44,155 (68%) would have been ineligible for screening. Of the
patients who did not qualify, 27,653 (63%) were aged >75years, 10,603 (24%)
were aged <65years, and 16,103 (36%) were women. In conclusion, the majority of
patients with a ruptured AAA did not meet criteria for screening, suggesting a need
for reconsideration of the current screening paradigm. Of those admitted with a
ruptured AAA, over half were older than 75 and almost a quarter were younger than
65 and with women making up a signicant portion of the population. Based on
prior risk factors such as age, cardiovascular disease and tobacco use, further studies are needed to design a more sensitive screening algorithm to capture the highrisk patients in these excluded populations.
The identical question of the extent to which rAAA patients would have been
covered by the US screening programme was addressed by Mota etal. [8] using the
Vascular Quality Initiative (VQI) patient population from 2003 to 2019. A total of
5340 patients underwent rAAA repair. The majority (66%) were screening- ineligible
according to the Centers for Medicare and Medicaid reimbursement guidelines. The
largest contributors to screening ineligibility were males less than 65years of age
with a smoking history or family history of AAA (25%), males greater than 75years
of age with a smoking history (25%), and females older than 65years of age with a
smoking history (19%). The data suggest that three high-risk populations may benet from expansion of AAA screening guidelines: males with a smoking history or
family history of AAA between ages 55 and 64years, female smokers older than
65years, and male smokers older than 75years who are otherwise in good health.
5.2.1.4 Screen Detected Sub-Aneurysmal Aortas
A population-based Swedish cohort study [9] aimed to evaluate the long-term natural course of men with a screen detected sub-aneurysmal aorta (SAA), that is an
aortic diameter of 25–29mm, regarding development to an AAA, with a focus on
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the proportion progressing to the threshold diameter for surgical repair (≥55mm).
Between 1 January 2006 and 31 December 2014, a total of 52,221 men were
screened. A total of 1020 men with SAA were detected (2.0%), of whom 940
(92.2%) had any follow up scan after the baseline screening. The Kaplan-Meier
estimated incidence of AAA≥30mm development after the 5year follow up was
65.8%, all <55 mm. The incidence after the 10 year follow up was 95.1%, and
29.7% reached ≥55 mm. All 41 SAAs that reached >55mm in diameter were
>30mm at the 5-year follow-up. 32 of these patients underwent AAA repair, with
100% survival. According to this study, a majority of SAAs eventually progress to
an AAA, of which 30% are estimated to eventually reach the threshold for repair
within 10years. The results indicate that the cohort of men with SAAs at risk of
later AAA repair can safely be identied by a single scan 5years after their initial
screening.
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5.2.2 Intact AAA: Randomized Trials
5.2.2.1 OVER-Trial
The Open versus Endovascular Repair (OVER) trial included a total of 881 randomized patients with asymptomatic AAA, 444 with EVAR and 437 with open repair
(OAR). The primary outcome was all-cause mortality. The 30-day mortality had
been 0.5% with EVAR and 2.5% with OAR.Lederle etal. [10] published long-term
results of this study. Patients were followed for up to 14years after randomisation.
A total of 302 patients (68.0%) in the endovascular-repair group and 306 (70.0%) in
the open-repair group died. During the rst 4years of follow-up, overall survival
appeared to be higher with endovascular repair than with open repair; from year 4
through year 8, overall survival was higher in the open-repair group; and after
8years, overall survival was once again higher in the endovascular-repair group.
None of these trends were signicant. In this study, long-term survival was similar
for EVAR and OAR, but the number of patients requiring a second procedure was
higher for EVAR (117/439; 26.7%) vs OAR (85/429; 19.8%). These results were
not consistent with the ndings of worse performance of endovascular repair with
respect to long-term survival that was seen in the two European trials. Of note,
deaths from cancer were not more common in the endovascular-repair group than in
the open-repair group, despite the presumed higher exposure to ionizing radiation
among patients in the endovascular-repair group. There were a total of 80 deaths
from cancer in the endovascular-repair group (18%) and 85in the open-repair group
(19.5%).
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5 Abdominal Aortic Aneurysm (AAA)
5.2.2.2 EVAR-2 Trial
The randomized EVAR-2 trial is the sole randomized trial to identify whether EVAR
reduces mortality in patients physically ineligible for open repair [11]. Between
September 1, 1999 and August 31, 2004, 404 patients were recruited. Patients of
both sexes who were at least 60years of age with large aneurysms (≥5.5cm in
diameter) and deemed physically ineligible for open repair were randomly assigned
(1:1) to undergo either endovascular repair (n=197) or no-intervention (n=207).
Mean follow-up until death or censoring was 4.2years. There were 187 deaths (22.6
per 100 person-years) in the EVAR group and 194 (22.1 per 100 person-years) in
the no-intervention group. By 12 years of follow-up the estimated survival was
5.3% in the EVAR group and 8.5% in the no-intervention group; there was no signicant difference in life expectancy between the groups (both 4.2years; P=0.97).
However, overall aneurysm-related mortality was signicantly lower in the EVAR
group (3.3 deaths per 100 person-years compared with 6.5 deaths per 100 personyears in the no-intervention group, P=0.019). In this trial, EVAR did not increase
overall life expectancy in patients ineligible for open repair, but could reduce
aneurysm- related mortality.
5.2.2.3 Mesenteric Artery Embolisation/Aneurysm Sac Coil Embolisation
Samura etal. [12] aimed to evaluate the effect of inferior mesenteric artery (IMA)
embolization during endovascular aneurysm repair (EVAR) in patients at high risk
of type II endoleak (T2EL) in a randomized controlled trial (RCT). High risk T2EL
was dened as IMA patency with (1) IMA≥3mm, (2) lumbar arteries >2mm, or
(3) an aortoiliac-type aneurysm. For embolistion mainly the Amplatzer Vascular
Plug was used. 106 patients were randomized. The incidence of T2EL was signicantly lower in the embolisation group with 24.5% vs. 49.1% in the control group
(p=0.009). The median follow-up time was 20.0±10.8months in the intention-totreat analysis. The aneurysm sac shrunk signicantly more in the treatment group
(−5.7±7.3mm vs. −2.8±6.6mm; p=0.037) and the incidence of aneurysm sac
growth related to a T2EL was signicantly lower with embolisation (3.8% vs.
17.0%; p=0.030). Complications or reinterventions due to IMA embolisation were
not seen. The data recommend the method for prevention of T2EL in the dened
risk group.
A second randomised study [13] also addressed the prevention of T2-EL.In this
so-called SCOPE 1 (Sac COil embolisation for Prevention of Endoleak) study,
patients at high risk of type II EL were randomised to standard EVAR (n=47) or
EVAR with non-selective aneurysm sac coil embolisation (ASCE; n=47). Before
deployment of the contralateral iliac extension, a guidewire was pushed in the aneurysm sac. After deployment of the contralateral iliac extension, a microcatheter was
placed in the sac to perform non-selective embolisation using removable coils.
There were no intraoperative complications. At 12months, a signicant reduction
in T2EL rate was seen, 40.5% with standard EVAR vs. 14.3% with coil
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embolisation. Freedom from EL and reinterventions was signicantly higher with
embolisation (26/47 events with standard EVAR vs.11/47 with coil embolisation).
Aneurysm sac volume and diameter decreased signicantly in the embolisation
group compared to control. Spinal cord ischaemia, colonic infarction or coil migration were not observed after coil embolisation. For selected patients at risk of EL,
ASCE seems effective in preventing EL at 1, 6, and at 12months. However, the
difference was not statistically signicant at 24months. ASCE decreases the reintervention rate 2 years after EVAR. A signicantly faster aneurysm volume
shrinkage was observed at 1 and 2years following surgery. Non-selective embolisation of the aneurysm sac seems safe and not technically demanding.
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5.2.3 Intact AAA: Meta-Analyses
5.2.3.1 Surgery forSmall Asymptomatic Abdominal Aortic Aneurysms
Guidelines recommend repair of large asymptomatic AAAs (greater than 5.5cm in
diameter). Debate continues over the roles of early repair versus surveillance with
repair on subsequent enlargement in people with asymptomatic AAAs of 4.0–5.5cm
diameter. A Cochrane review was prepared to compare mortality and costs, as well
as quality of life and aneurysm rupture as secondary outcomes, following early
surgical repair versus routine ultrasound surveillance in people with asymptomatic
AAAs between 4.0 and 5.5cm in diameter [14]. Four trials with 3314 participants
fullled the inclusion criteria. There was no evidence of an advantage to early repair
for small AAA (4.0–5.5cm), regardless of whether open repair or EVAR is used
and, at least for open repair, regardless of patient age and AAA diameter. Thus,
neither early open nor early EVAR of small AAAs is supported by currently available evidence.
5.2.3.2 EVAR vs. Open Surgical Repair
A meta-analysis was undertaken of published high-quality long-term data of EVAR
vs. open surgical repair for unruptured AAA [15]. Seven RCTs reporting a total of
2983 patients, 1518 of whom underwent EVAR and the remaining 1465 open repair,
were included in quantitative synthesis. Meta-analysis found signicantly lower
odds of 30 day (OR, 0.36; 95% CI 0.20–0.66) and in hospital mortality with
EVAR. Meta-analysis of the three trials reporting long term follow up found no
signicant difference in all cause mortality at any time between EVAR and open
repair. The hazard of all cause (HR 0.62; 95% CI 0.42–0.91) and aneurysm related
death within 6 months (HR 0.42; 95% CI 0.24–0.75) was signicantly lower in
patients who underwent EVAR, but with further follow up, the pooled hazard estimate moved in favour of open surgery; in the long term (>8years) the hazard of
aneurysm related mortality was signicantly higher after EVAR (HR 5.12; 95% CI
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5 Abdominal Aortic Aneurysm (AAA)
1.59–16.44). Compared with open surgery, EVAR results in a better outcome during
the rst 6months but carries an increased risk of aneurysm related mortality after
8years.
Another meta-analysis of long-term outcomes of EVAR vs open repair was based
on 3 randomised trials and 68 observational studies including 151,092 (EVAR) and
148,692 (OAR) patients, respectively [16]. In this analysis, EVAR was associated
with higher long-term all-cause mortality, reintervention and secondary rupture
rates compared to OAR.However, subanalysis of more recent studies, with last year
of patient recruitment 2010 or after, demonstrated no long-term mortality differences between EVAR and OAR.
Finally, Bulder etal. [17] included 53 studies in a meta-analysis. They reported
lower 30-day mortality rate for EVAR (1.16%) compared to OAR (3.27%). There
were no signicant differences in long-term survival between the two procedures
(hazard ratios 1.01, 1.00 and 0.98 for 3, 5 and 10years respectively; p= 0.721,
p=0.912 and P= 0.777, respectively). Correction of age inequality by means of
relative survival analysis showed equal long-term survival: 0·94, 0·91 and 0·76 at 3,
5 and 10years for EVAR, and 0·96, 0·91 and 0·76 respectively for OAR.Although
the relative survival analysis took age and sex differences into account, other patient
characteristics that may inuence the choice of treatment between EVAR and OAR
could not be corrected for. Yet, asymmetrical medical decision-making as result of
the higher intervention threshold for OAR presumably results in over-representation
of ‘healthier’ patients in the OAR group. As such, conclusions from this metaanalysis may underestimate the benet of EVAR.Available data do not allow extension beyond the 10-year survival window or analysis of specic subgroups.
5.2.3.3 Gender-Specic Differences inOutcome
Liu etal. [18] conducted a comprehensive systematic review and meta-analysis of
all available studies reporting sex differences after EVAR for infrarenal AAA.Thirtysix cohorts were included in this meta-analysis. 25 cohorts investigated intact AAA,
7 investigated ruptured AAA, and 4 investigated indeterminate AAA.The pooled
results showed that women were associated with a signicantly increased risk of
30-day mortality (crude OR, 1.67; P<.001; adjusted OR, 1.73; P<.001), in- hospital
mortality (OR, 1.90), limb ischemia (OR, 2.44), renal complications (OR, 1.73),
cardiac complications (OR, 1.68), and long-term all-cause mortality (hazard ratio,
1.23) compared with men after EVAR for infrarenal AAA.However, no signicant
difference was observed between sexes for visceral/mesenteric ischemia, 30-day
reinterventions, late endoleaks and late reinterventions. Women should be enrolled
in a strict and regular long-term surveillance after EVAR.
A second meta-analysis [19] and systematic review of sex specic differences in
30-day mortality and complications demonstrated that the risk of worse outcomes
in women (vs. men) after elective abdominal aortic aneurysm repair has not ameliorated with time and the risk ratio for mortality is higher for EVAR than open repair.
26 studies (371,215 men, 65,465 women) were included. Mortality risk was higher
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in women for OAR (OR 1.49) and more so for EVAR (OR 1.86). Over the last
20years, this difference remained unchanged. Transfusions, pulmonary complications, and bowel ischaemia were more common in women after OAR and
EVAR.Better pre-operative optimisation might reduce the higher risk of systemic
complications in women. Arterial injury, renal, and other ischaemic complications
(limb and bowel ischaemia), which probably contribute to mortality, are higher in
women, especially after EVAR, and may be avoidable with strategic planning.
5.2.3.4 EVAR: Reintervention Rate
A systematic review and meta-analysis of the available literature to determine longterm freedom from reintervention after EVAR and the change in reintervention rates
over time was performed by Wanken etal. [20]. A total of 30 studies (randomized
trials, n=3; observational studies, n=27) comprising 32,126 patients were included.
The probability of freedom from reintervention was 81% at 5years, 70% at 10years
and 64% at 14 years. Freedom from reintervention improved linearly over time,
from 90% to 94% after 1year (years 1998 vs 2008), from 77% to 90% after 3years,
and from 68% to 81% after 5years. At 7years, estimated freedom from reintervention improved from 51% in 1998 to 86% in 2011. EVAR patients remain at risk for
reintervention indenitely, and therefore lifelong surveillance is imperative.
Encouragingly, reintervention rates have improved over time, with newer devices
exhibiting lower rates. Reintervention rate remains an important metric for new
devices and registries.
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5.2.4 Ruptured AAA: Meta-Analyses
5.2.4.1 EVAR vs. OAR
A meta-analysis by Kontopodis etal. [21] is available on the perioperative mortality
of endovascular aneurysm repair (EVAR) vs. open repair (OAR) for ruptured
abdominal aortic aneurysm (rAAA). 136 studies were included in quantitative synthesis reporting a total of 267,259 patients (EVAR 58273; open surgery 208,986).
The pooled peri-operative mortality of EVAR and OAR was 0.245 (95% CI
0.234–0.257) and 0.378 (95% CI 0.364–0.392), respectively. EVAR was associated
with reduced peri-operative mortality (OR 0.54, 95% CI 0.51–0.57, p< .001). If
EVAR can be done, it is a better treatment for ruptured AAA in view of the reduced
perioperative mortality compared with OAR. The outcomes of both EVAR and
OAR have improved over the years, and the difference in perioperative mortality in
favour of EVAR has become more pronounced. There is a signicant association
between peri-operative mortality and institutional case load for open repair of
rAAA.The data support the statement that, when feasible, EVAR is the preferred
procedure in the management of rAAA.
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Kontopodis etal. [22] also prepared a systematic review with meta-analysis on
late outcomes of EVAR vs. OAR for rAAA.Three randomized controlled trials and
22 observational studies reporting a total of 31,383 patients were included in the
quantitative synthesis (mean follow-up ranged from 232days to 4.9 years). The
overall all-cause mortality was signicantly lower after EVAR than after OAR (HR,
0.79; 95% CI, 0.73–0.86). However, the post discharge all-cause mortality was not
signicantly different (HR, 1.10; 95% CI, 0.85–1.43). Similarly, aneurysm-related
mortality, reported in only one randomised trial, was not different between EVAR
and OAR (HR, 0.89; 95% CI, 0.69–1.15). The mortality difference in favour of
EVAR was more pronounced in the more recent trials. The data demonstrate that the
perioperative survival advantage of EVAR over OAR is maintained at follow-up,
which argues for a wider adoption of an EVAR rst strategy for rAAA.
5.2.4.2 Procedure Volume andOutcomes After rAAA Repair
The objective of a systematic review by Kontopodis et al. [23] was to test the
hypothesis that institutions or surgeons with higher AAA case volumes confer
improved outcomes for patients with rAAA.Thirteen studies reporting a total of
120,116 patients were included. Patients treated in low-volume centres had a statistically signicantly higher perioperative mortality than those treated in high-volume
centres (odds ratio 1.39; 95% CI 1.22–1.59). Subgroup analysis showed a mortality
difference in favour of high volume centres for both EVAR (OR 1.61, 95% CI
1.11–2.35) and OAR (OR 1.50, 95% CI 1.25–1.81). Adjusted analysis showed a
benet of treatment in high volume centres for OAR but not for EVAR.Differences
in perioperative mortality between low and high volume surgeons were not statistically signicant for either EVAR or OAR.A high institutional volume may result in
a reduction in perioperative mortality following surgery for rAAA.These ndings
have implications for vascular service provision, with an emphasis on the centralisation of aortic services and the potential to enhance clinical outcomes.
5.2.4.3 rAAA inOctogenarians
A meta-analysis sought to identify the mortality and ambulatory state 30days and
1year postoperatively in octogenarians treated for rAAA by EVAR or OAR [24].
Eight retrospective studies could be included, reporting on 7526 patients. Metaanalysis showed a pooled 30-day mortality of 43% (95% condence interval (CI)
33–53) and a 1-year mortality of 47%. Compared with OAR, patients after EVAR
had a signicant lower mortality at 30days (risk ratio (RR) 0.50, 95% CI 0.38–0.67)
and at 1year (RR 0.65, 95% CI 0.44–0.96). The 30day and 1year mortality rates
for rAAA repair in octogenarians are similar to the outcome at all ages, with a signicant survival advantage of EVAR over OAR.Patients should therefore not be
denied treatment of a rAAA based on age alone.
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5.2.4.4 Weekend Admission ofrAAA
A meta-analysis was undertaken to determine whether weekend admission for
rAAA is associated with poorer outcomes [25]. Twelve observational cohort studies
published between 2001 and 2019 comprising 14 patient cohorts with a total of
95,856 patients were eligible for quantitative synthesis. Patients presenting on a
weekend had a signicantly higher risk of unadjusted in-hospital (OR 1.20, 95% CI
1.10–1.31, p<.001). Both the unadjusted 30day mortality risk (OR 1.16, 95% CI
0.98–1.39, p = .090) and unadjusted 90 day mortality risk (OR 1.12, 95% CI
0.90–1.40, p = .30) were higher for those presenting at a weekend, but neither
reached statistical signicance. There was a signicantly greater risk of combined
unadjusted in hospital, 30 and 90day mortality for those presenting at a weekend
(OR 1.17, 95% CI 1.09–1.27, p<.001). Hospital length of stay was not statistically
different between groups. There is an association between weekend admission and
higher mortality in patients presenting with rAAAs. Services should be reviewed to
ensure that high quality emergency vascular care can be provided reliably at the
weekend at an equitable level to the weekday service.
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5.2.5 Studies andRegistries
5.2.5.1 Long-Term Outcomes ofEVAR vs. OAR
Long-term outcomes of endovascular vs open repair of abdominal aortic aneurysm
were identied in a multicenter retrospective cohort study using data with 6-year
follow-up from the Medicare-matched Vascular Quality Initiative Vascular Implant
Surveillance and Interventional Outcomes Network database [26]. Among a total of
32,760 patients who underwent surgical abdominal aortic aneurysm repair, 28,281
patients underwent endovascular repair and 4479 patients underwent open repair.
After propensity score matching, there were 2852 patients in each group. OAR was
associated with signicantly lower 6-year mortality (35.6%) compared with EVAR
(41.2%; P= .002). OAR, compared with EVAR, also was associated with signicantly lower rates of 6-year rupture and reintervention. Open repair was associated
with signicantly higher odds of 30-day mortality (OR, 3.56; 95% CI, 2.41–5.26;
P<.001) and complications (Table5.1). The authors concluded that although EVAR
remains a highly valuable treatment modality, especially in patients who are not
candidates for open surgery, OAR should be carefully considered in patients who
may be poor candidates for EVAR.
Long-term outcomes of EVAR compared with open surgical repair for unruptured AAAs were analyzed by Epple etal. [27] in a retrospective cohort study using
health insurance data from Germany. Among 20,683 patients, 15,792 (76.4%)
underwent EVAR and 4891 (23.6%) underwent OAR.From these patients, 4886
well-balanced propensity score–matched pairs of patients were dened. Perioperative
mortality was 1.9% after endovascular and 5.9% after open repair (P≤.001). The
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Table 5.1 Outcomes after elective endovascular (EVAR) and open (OAR) abdominal aortic
aneurysm repair. Vascular Quality Initiative data from 2003 to 2018. Propensity score matched
comparison (according to [26])
Parameter EVAR (n=2842) OAR (n=2842) P
Perioperative outcome
– Death, n (%) 33 (1.2) 114 (4.0) <.001
– Leg ischaemia, n (%) 25 (0.9) 58 (2.0) <.001
– Intestinal ischaemia, n (%) 10 (0.4) 121 (4.3) <.001
– Respiratory complications, n (%) 57 (2.0) 302 (10.6) <.001
– Nonhome discharge, n (%) 207 (7.3) 813 (28.6) <.001
Death
– 1year, n (%) 241 (9.2) 253 (9.3) .49
– 6years, n (%) 608 (41.2) 548 (35.6) .002
Rupture
– 6years, n (%) 149 (8.3) 117 (5.8) .03
Reintervention
– 6years, n (%) 267 (16.0) 190 (11.6) <.001
5 Abdominal Aortic Aneurysm (AAA)
benet of lower mortality with EVAR was seen in all analyzed age groups and in
both, men and women. The length of hospital stay was signicantly shorter (EVAR
mean: 13.0days, OAR mean: 20.3days, P≤.001) and the rate of patients requiring
blood transfusions was signicantly lower with EVAR (14.0% vs 60.8%, P≤.001).
The early survival benet after endovascular repair persisted for approximately
3years (EVAR estimated survival rate 82.3%, OAR 80.9%, P= .021). After that
time the estimated survival curves were similar. After 9years estimated survival was
51.2% among patients in the EVAR cohort as compared to 52.8% in the OAR cohort
(P=.102). The decision between EVAR or OAR may depend on patient preference,
surgeons’ experience, and the institutions’ ability to handle complications.
Varkevisser et al. [28] used the Society of Vascular Surgery Vascular Quality
Initiative (VQI) clinical registry to investigate the differences in long-term all-cause
mortality between EVAR and open repair for infrarenal AAA stratied by age.
48,074 patients undergoing elective infrarenal abdominal aneurysm repair (89%
EVAR) were identied, including 7940 patients aged less than 65, 29,555 aged
between 65 and 79, and 10,579 aged 80years or more. EVAR was associated with
a higher propensity score-adjusted long-term hazard of mortality compared with
open repair in the cohort aged less than 65years (HR 1.39; P=.026). The mortality
was similar in the age cohort between 65 and 79 (HR 0.94; P=.43), whereas EVAR
was associated with a lower hazard of mortality in the cohort aged 80years or more
(HR 0.63; P= .004). These results suggest that a young, healthy patient with low
operative risk and a long life expectancy may be considered for open AAA repair,
whereas EVAR remains the preferred treatment for most AAA patients.
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