Abstract
Knowledge regarding the long-term outcomes of elective treatment of abdominal aortic aneurysm (AAA) using endovascular aortic repair (EVAR) is increasing. However, data with greater than 10 years' follow-up remain sparse and are lacking from population-based studies. To determine the long-term outcomes of EVAR compared with open surgical repair (OSR) for elective treatment of AAA. This retrospective, population-based cohort study used linked administrative health data from Ontario, Canada, to identify all patients 40 years and older who underwent elective EVAR or OSR for AAA repair from April 1, 2003, to March 31, 2016, with follow-up terminating on March 31, 2017. A total of 17 683 patients were identified using validated procedure and billing codes and were propensity score matched. Analysis was conducted from June 26, 2018, to January 16, 2019. Elective EVAR or OSR for AAA. The primary outcome was overall survival. Secondary outcomes were major adverse cardiovascular event-free survival, defined as being free of death, myocardial infarction, or stroke; reintervention; and secondary rupture. Among 17 683 patients who received elective AAA repairs (mean [SD] age, 72.6 [7.8] years; 14 286 [80.8%] men), 6100 (34.5%) underwent EVAR and 11 583 (65.5%) underwent OSR. From these patients, 4010 well-balanced propensity score-matched pairs of patients were defined, with a mean (SD) age of 73.0 (7.6) years and 6583 (82.1%) men. In the matched cohort, the mean (SD) follow-up was 4.4 (2.7) years, and maximum follow-up was 13.8 years. The overall median survival was 8.9 years. Compared with OSR, EVAR was associated with a higher survival rate up to 1 year after repair (91.0% [95% CI, 90.1%-91.9%] vs 94.0% [95% CI, 93.3%-94.7%]) and a higher major adverse cardiovascular event-free survival rate up to 4 years after repair (69.9% [95% CI, 68.3%-71.3%] vs 72.9% [95% CI, 71.4%-74.4%]). Cumulative incidence of reintervention was higher among patients who underwent EVAR compared with those who underwent OSR at the 7-year follow-up (45.9% [95% CI, 44.1%-47.8%] vs 42.2% [95% CI, 40.4%-44.0%]). Survival analyses demonstrated no statistically significant differences in long-term survival, reintervention, and secondary rupture for patients who underwent EVAR compared with those who underwent OSR. Kaplan-Meier analysis suggested superior long-term major adverse cardiovascular event-free survival among patients who underwent EVAR compared with those who underwent OSR (32.6% [95% CI, 26.9%-38.4%] vs 14.1% [95% CI, 4.0%-30.4%]; stratified log-rank P < .001) during a maximum follow-up of 13.8 years. Endovascular aortic repair was not associated with a difference in long-term survival during more than 13 years' maximum follow-up. The reasons for these findings will require studies to consider specific graft makes and models, adherence to instructions for use, and types and reasons for reintervention.
Highlights
Compared with open surgical repair (OSR), Endovascular aortic repair (EVAR) was associated with a higher survival rate up to 1 year after repair (91.0% [95% CI, 90.1%-91.9%] vs 94.0% [95% CI, 93.3%-94.7%]) and a higher major adverse cardiovascular event–free survival rate up to 4 years after repair (69.9% [95% CI, 68.3%-71.3%] vs 72.9% [95% CI, 71.4%-74.4%])
Cumulative incidence of reintervention was higher among patients who underwent EVAR compared with those who underwent OSR at the 7-year follow-up (45.9% [95% CI, 44.1%-47.8%] vs 42.2% [95% CI, 40.4%-44.0%])
Endovascular aortic repair was not associated with a difference in long-term survival during more than 13 years’ maximum follow-up
Summary
Endovascular aortic repair (EVAR) has changed the landscape of abdominal aortic aneurysm (AAA) treatment since its introduction in 1991.1 Randomized and population-based studies investigating EVAR vs open surgical repair (OSR) demonstrated superior perioperative survival as well as significant improvements in operative time, blood loss, transfusion requirements, cardiopulmonary complications, and reduced lengths of stay in intensive care units and hospitals in favor of EVAR.[2,3,4] EVAR has seen rapid uptake and has become the predominant approach to AAA management, as borne out by multiple Canadian,[5] US, and European[8] studies.Despite its clear short-term superiority, early EVAR technology had unique complications, including endoleak, graft migration, graft thrombosis, and secondary rupture.[9,10,11,12] patients who undergo EVAR require lifelong surveillance to identify and prevent these complications, and EVAR is associated with significantly higher reintervention rates.[13]. Endovascular aortic repair (EVAR) has changed the landscape of abdominal aortic aneurysm (AAA) treatment since its introduction in 1991.1 Randomized and population-based studies investigating EVAR vs open surgical repair (OSR) demonstrated superior perioperative survival as well as significant improvements in operative time, blood loss, transfusion requirements, cardiopulmonary complications, and reduced lengths of stay in intensive care units and hospitals in favor of EVAR.[2,3,4] EVAR has seen rapid uptake and has become the predominant approach to AAA management, as borne out by multiple Canadian,[5] US, and European[8] studies. The Endovascular Aortic Repair 1 (EVAR-1) trial[17] and Dutch Randomized Endovascular Aneurysm Management (DREAM)[18] trial are the only trials to report longer than 10-year follow-up, and no population-based studies have been conducted with longer than 10 years of follow-up, to our knowledge
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