Delays in Treatment Are Associated With Increased Mortality in Patients Undergoing Endovascular Repair of Abdominal Aortic Aneurysms

Abstract

This study aims to evaluate the association between delays in treatment and outcomes after endovascular aneurysm repair (EVAR). A retrospective analysis of consecutive patients undergoing EVAR for abdominal aortic aneurysm (AAA) between January 1998 and December 2019 was performed. Patients undergoing early EVAR (within less than 8 weeks after meeting size threshold for repair) were compared with delayed EVAR (8 weeks or more). The primary outcome was freedom from all-cause mortality. Secondary outcomes were sac regression (defined as a reduction in AAA diameter by 5 mm or more), freedom from reinterventions, 30-day mortality, and complications. Variables were compared using the χ2 test or the Student t test as appropriate. Kaplan-Meier survival curves and Cox regression proportional hazards models were used. A P value of <.05 was considered significant. The study consisted of 513 patients (83% male) with 33% (n = 170) and 67% (n = 343) undergoing early and delayed EVAR, respectively. Early EVAR patients had a larger mean AAA diameter (60 ± 13 mm vs 54 ± 7 mm in delayed EVAR; P < .001). There were no major differences in medical comorbidities between the groups (Table). Operative timing was longer in the early group (119 ± 42 minutes vs 108 ± 45 minutes in delayed; P = .019). Kaplan-Meier survival estimates show that freedom from all-cause mortality was 90% in early EVAR vs 82% in delayed EVAR (P = .023; Fig) at a mean of 25.8 months. Sac regression was similar between the two groups at 54% and 45% for early and delayed EVAR, respectively (P = .304). In addition, freedom from reinterventions was 78% in early EVAR and 83% in delayed EVAR (P = .364). Perioperative mortality was 0% in both groups. Perioperative complication rates were similar at 11% and 9% in early and delayed EVAR, respectively. The Cox regression proportional hazards model showed that delayed EVAR predicted increased mortality (hazard ratio: 1.886, 95% confidence interval [CI]: 1.083-3.285; P = .025). The effect persisted after adjusting for age, AAA diameter, and comorbidities (hazard ratio: 2.597, 95% CI: 1.350-4.998; P = .004). Patient undergoing EVAR within less than 8 weeks after meeting indications for repair tend to have larger aneurysms. Delaying EVAR beyond 8 weeks was associated with increased all-cause mortality after adjusting for preoperative AAA diameter, age, and comorbidities. These findings suggest the need to adopt a pathway that permits expedited treatment within 8 weeks of meeting indications for repair.TableBaseline characteristics of early and delayed EVAR patientsCharacteristicEarlyDelayedP valueAge, mean (SD), years77 (8)77 (8).873Male sex, % (No.)87 (147)80 (275).090Mean AAA diameter, mean (SD), mm60 (13)54 (7)<.001Comorbidities, % (No.) Cardiac37 (63)37 (127).994 Respiratory21 (36)25 (87).296 Hemodialysis01 (4).157 HTN48 (82)55 (189).143 DM12 (20)15 (50).382 Dyslipidemia47 (79)56 (191).049 PAD11 (18)10 (34).811 Active or previous cancer14 (23)11 (36).316 Active smoking15 (24)20 (66).137Medications, % (No.) β-Blockers31 (52)34 (116).437 ACEI/ARB24 (41)34 (116).022 CCB18 (30)21 (73).326 Statin41 (70)53 (182).010 Antiplatelets38 (65)51 (175).006 Anticoagulation11 (19)11 (36).815AAA, Abdominal aortic aneurysm; ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; CCB, calcium channel blockers; DM, diabetes mellitus; EVAR, endovascular aortic repair; HTN, hypertension; PAD, peripheral arterial disease. Open table in a new tab