Era of endovascular aortic aneurysm repair is linked to preoperative anatomic severity and perioperative patient outcomes

Abstract

Varying opinions on optimal elective and emergent surgical management of infrarenal abdominal aortic aneurysms are expressed by the most recent Society for Vascular Surgery (SVS), European Society for Vascular Surgery, vs UK National Institutes for Health and Care Excellence guidelines. The UK National Institutes for Health and Care Excellence guidelines propose that open surgical repair serve as the default treatment for infrarenal abdominal aortic aneurysm. The rationale for this approach relied on data from the early era of endovascular aneurysm repair (EVAR) and are in contrast to the more balanced approaches of the SVS and European Society for Vascular Surgery. We hypothesize that significant differences in patient selection, management, and postoperative outcome are related to the era in which treatment was undertaken, contextualizing the outcomes reported in early-era EVAR randomized controlled trials. Retrospectively, two cohorts representing all EVAR patients from "early" (n= 167; 2008-2010) and "late" (n= 129; 2015-2017) periods at a single treating institution were assembled. Primary outcomes of era-related changes in preoperative demographics, anatomy, and intraoperative events were assessed; anatomy was compared using the SVS anatomic severity grading system. These era-related differences were then placed in the context of early perioperative outcomes and at follow-up to 1year. Choice of surgical strategy differed by era, despite the same patient preoperative comorbidities between EVAR groups. Preoperative anatomic severity was significantly worse in the early cohort (P< .001), with adverse proximal and distal seal zone features (P< .001). Technical success was 16.2% higher in the late cohort, with significantly fewer type 1A/B endoleaks perioperatively (P< .001). In-hospital complications, driven by higher acute kidney injury and surgical site complications in the early cohort, resulted in a 16.5% difference between cohorts (P< .05). At 1year of follow-up, outcome differences persisted; late-era patients had fewer 1A endoleaks, fewer graft complications, and better reintervention-free survival. From a granular dataset of EVAR patients, we found an impact of EVAR repair era on early clinical outcomes; late cohort infrarenal EVAR patients had less severe preoperative anatomy and improved perioperative and follow-up outcomes to 1year, suggesting that the results of early EVAR randomized controlled trials may no longer be generalizable to modern practice.