Comment on ‘Endovascular Repair of Abdominal Aortic Aneurysm Does Not Improve Early Survival versus Open Repair in Patients Younger than 60 Years’

Abstract

We were interested to read the retrospective study by Gupta et al.1Gupta P.K. Ramanan B. Lynch T.G. Gupta H. Fang X. Balters M. et al.Endovascular repair of abdominal aortic aneurysm does not improve early survival versus open repair in patients younger than 60 years.Eur J Vasc Endovasc Surg. 2012; 43: 506-512Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar which compared endovascular repair of abdominal aortic aneurysm (AAA) with open repair in patients younger than 60 years of age. Not surprisingly this constituted a small percentage of the total number of AAA repairs performed within the 2007-9 NSQIP data and as such is a unique cohort worthy of study. By the very nature of the study design the authors were unable to undertake a randomised approach or adequately match their two comparison groups. As such they have opened their study to considerable selection bias. Leaving patient allocation to EVAR or open repair to individual clinicians and hospitals is likely to lead to varying risk profiles between the two groups with treatment choice likely based on factors such as aneurysm size and patient co-morbidities. In their discussion, the authors go onto compare their study to previous trials such as the EVAR1 and DREAM study. In order to be included in the EVAR1 and DREAM trials, aneurysm size had to be greater than 5.5 and 5 cm in size respectively.2Greenhalgh R.M. Brown L.C. Kwong G.P. Powell J.T. Thompson S.G. Comparison of endovascular aneurysm repair with open repair in patients with abdominal aortic aneurysm (EVAR trial 1), 30-day operative mortality results: randomised controlled trial.Lancet. 2004; 364: 843-848Abstract Full Text Full Text PDF PubMed Scopus (1634) Google Scholar, 3Prinssen M. Verhoeven E.L. Buth J. Cuypers P.W. van Sambeek M.R. Balm R. et al.A randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms.N Engl J Med. 2004; 351: 1607-1618Crossref PubMed Scopus (1665) Google Scholar The present study did not, however, have such strict inclusion criteria, with no data on aneurysm size available. We know that 30 day mortality rates were higher in both the EVAR1 and DREAM trials than that of the current study, with the authors putting this down to the older age of the patients and associated increase in co-morbidities. However, without knowing the aneurysm size of included patients we feel it would be unwise to compare mortality outcomes between this study and previous ones. In conclusion, we feel that if we are to use a study as part of the informed consent process for patients then these important issues should be addressed. Endovascular Repair of Abdominal Aortic Aneurysm does not Improve Early Survival versus Open Repair in Patients Younger than 60 YearsEuropean Journal of Vascular and Endovascular SurgeryVol. 43Issue 5PreviewMultiple randomised trials have demonstrated lower perioperative mortality after endovascular aneurysm repair (EVAR) compared to open surgical repair for infrarenal abdominal aortic aneurysms (AAAs). However, in these trials the mortality advantage for EVAR is being lost within 2 years of repair and the patients evaluated are relatively older with no study specifically comparing EVAR and open repair for patients younger than 60 years of age. Full-Text PDF Open Archive