Assessment of International Outcomes of Intact Abdominal Aortic Aneurysm Repair over Nine Years

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Introduction - Case mix and outcomes of complex surgical procedures vary over time and between regions.1 With noted increasing surgical activity and screening programmes for abdominal aortic aneurysm (AAA) detection and management, the monitoring of surgical outcome measures is increasingly important.2–4 The objective of this study is to describe trends in contemporary AAA practice in an international context, and assess the change in perioperative mortality after repair. Methods - Data on primary AAA repair from vascular surgery registries in 11 countries for the years 2005-2009 and 2010-2013 were analyzed. Data were analyzed overall, per country, per treatment (EVAR vs. open surgery), for high- and low-volume centres, and also between the two time periods (2005-2009 and 2010-2013). The primary outcome was perioperative mortality, defined as either in-hospital death or death within 30 days. Multivariable-adjusted logistic regression analyses were carried out to adjust for variations in case mix. Results - There were 83 253 patients included. Over the two periods, the proportion of patients ≥80 years old increased (18.5% vs. 23.1%; p<0.0001), as well as endovascular repair (EVAR) (44.3% vs. 60.6; p<0.0001). AAAs less than 5.5 cm in the latter period was 25.8%. The mean annual volume of open repairs per center decreased from 12.9 to 10.6 between the two periods, p<0.0001, while it increased for EVAR from 10.0 to 17.1, p<0.0001. Overall, perioperative mortality fell from 3.0% to 2.4% (p<0.0001). Mortality for EVAR decreased from 1.5% to 1.1% (p<0.0001), while the outcome worsened for open repair (3.9% vs. 4.4%, p=0.008). The perioperative risk was greater for octogenarians (Overall, 3.6% vs. 2.1%, p<0.0001; Open, 9.5% vs. 3.6%, p<0.0001; EVAR, 1.8% vs. 0.7%, p<0.0001), and women (Overall, 3.8% vs. 2.2%, p<0.0001; Open, 6.0% vs. 4.0%, p<0.0001; EVAR, 1.9% vs. 0.9%, p<0.0001). Perioperative mortality after repair of AAAs<5.5 cm was 4.4% with open repair and 1.0% with EVAR, p<0.0001. Conclusion - In this large international cohort, total perioperative mortality continues to fall for the treatment of intact AAAs. EVAR procedures now exceed the number of open procedures. Mortality after EVAR has decreased, while mortality for open operations has increased. The perioperative mortality for small AAA treatment, particularly open surgical repair, is still considerable and should be weighed against the risk of rupture. References1Beck AW, Sedrakyan A, Mao J, Venermo M, Faizer R, Debus S, et al. Variations in Abdominal Aortic Aneurysm Care: A Report from the International Consortium of Vascular Registries. Circulation 2016;134(24):1948–58.2Schwarze ML, Shen Y, Hemmerich J, Dale W. Age-related trends in utilization and outcome of open and endovascular repair for abdominal aortic aneurysm in the United States, 2001-2006. J Vasc Surg 2009;50(4):722-9.e2.3Chun KC, Teng KY, Van Spyk EN, Carson JG, Lee ES. Outcomes of an abdominal aortic aneurysm screening program. J Vasc Surg 2013;57(2):376–81.4Mani K, Lees T, Beiles B, Jensen LP, Venermo M, Simo G, et al. Treatment of abdominal aortic aneurysm in nine countries 2005-2009: A vascunet report. Eur J Vasc Endovasc Surg 2011;42(5):598–607.