Endovascular Aneurysm Repair First for Ruptured Abdominal Aortic Aneurysm Might Not Be Applicable To All and Every Case

Abstract

We evaluated the relationship between the case volume (CV) and mortality outcomes after both open aneurysm repair (OAR) and endovascular aneurysm repair (EVAR) of elective (e) and ruptured (r) abdominal aortic aneurysms using a contemporary administrative database. The Healthcare Cost and Utilization Project Database for New York (2016) and New Jersey/Maryland/Florida (2016-2017) were queried using the International Classification of Diseases, 10th revision, to identify patients who had undergone OAR and EVAR. The hospitals were categorized into quartiles (Q) per overall (EVAR+OAR) volume and OAR-alone volume. Cox regression analysis adjusted for confounding factors was used to estimate the hazard ratios for mortality. A total of 8825 patients (mean age, 73.5 ± 9.5 years; 6861 men [77.7%]) had undergone 1355 OARs and 7470 EVARs. The overall CV had no effect on in-hospital mortality across the quartiles after eEVAR (range, 0.7%-1.4%; P = .15), rEVAR (range, 20.5%-29.6%; P = .63), or eOAR (range, 4.9%-8.8%; P = .21; Table). However, the rOAR mortality rates in the highest volume (Q4) hospitals were significantly lower than those in the three lower quartile hospitals (23.1% vs 44.7%; P < .001). When analyzed per OAR-alone volume, the same findings were observed (22.0% for Q4 vs 41.6% for Q1-Q3; P < .001; Table). Furthermore, in the Q4 hospitals, the mortality hazard between rEVAR (30.0%) and rOAR (37.2%) was similar per the overall volume analysis (hazard ratio, 1.64; 95% confidence interval, 0.91-2.9; P = .1). Per the OAR-alone volume analysis, the mortality hazard was greater for rEVAR (39.0%) than for rOAR (22.0%; hazard ratio, 2.3; 95% confidence interval, 1.02-5.34; P < .05). The mortality rates for eEVAR, rEVAR and eOAR are independent of the CV. However, after rOAR, the mortality rates in the Q4 hospitals were lower than those in the Q1 to Q3 hospitals, and, at least comparable, if not superior, to those of rEVAR. EVAR first for ruptured abdominal aortic aneurysms might not be applicable to all and every case. rOAR should be deferred to high-volume aortic OAR centers. Further studies are warranted to determine the factors accounting for the differences.TableFindings stratified by quartile and treatment typeaVariableQ1Q2Q3Q4Per overall volume1-15.5 Cases/y16-30 Cases/y31-52 Cases/y(≥53 Cases/yTotalP value rOAR52.540.440.423.137.2<.001 eOAR8.88.44.99.28.0.21 rEVAR24.820.529.626.525.3.63 eEVAR1.11.40.70.91.0.15Per OAR volume0.5-3 Cases/y4-8 Cases/y9-25 Cases/y≥26 Cases/y rOAR52.934.629.722.037.2<.001 eOAR9.75.97.110.08.0.13 rEVAR23.222.524.230.023.9.66 eEVAR1.10.71.01.71.0.28eEVAR, Elective endovascular aneurysm repair; EVAR, endovascular aneurysm repair; eOAR, elective open aneurysm repair; NA, not applicable; OAR, open aneurysm repair; rEVAR, ruptured endovascular aneurysm repair; rOAR, ruptured open aneurysm repair; Q, quartile.aMortality was stratified by overall (OAR+EVAR) and OAR-alone volume. Open table in a new tab