Era of Infrarenal Endovascular Aortic Aneurysm Repair Predicts Preoperative Anatomic Severity and Short-Term Patient Outcomes

Abstract

The release of the draft NICE (National Institutes for Health and Care Excellence, UK) guidelines, which proposed that infrarenal aortic aneurysm disease should be treated with open surgical repair in those fit and medical management in those unfit, with infrarenal endovascular aneurysm repair (irEVAR) confined to ruptures, has led to a reexamination of the evidence for EVAR. The rationale for this approach relied on data from the early era of EVAR. We hypothesized that significant differences in patient selection, management, and postoperative outcomes might depend on the irEVAR treatment era. A retrospective cohort of irEVAR patients from “early” (2008-2010) and “late” (2015-2017) periods at a single treating institution was assembled. Preoperative demographics and intraoperative events were abstracted by medical record review, and preoperative anatomy was assessed using the Society for Vascular Surgery anatomic severity grading system. Comparisons between the early and late era preoperative anatomy were performed in the context of early postoperative outcomes and device implantation characteristics. The choice of surgical strategy differed between the early and late cohort, with a more balanced usage of irEVAR, open surgical repair, and complex EVAR in the late cohort, despite no significant differences in preoperative comorbidities. Preoperative anatomic severity was significantly worse in the early cohort (P < .001), with adverse features contributed from proximal and distal seal zones (P < .001). Device manufacturer, configuration, stent number and size, and oversizing differed between cohorts (P < .05). Technical success was 16.2% greater in the late cohort, with significantly fewer type 1A/B endoleaks (P < .001). In-hospital complications, driven by a greater incidence of acute kidney injury and surgical site complications in the early cohort, resulted in a 16.5% difference between cohorts (P < .05); however, no differences were found in in-hospital mortality. We found an impact of irEVAR repair era on clinical outcome, with the late cohort irAAA patients more likely to be considered for a variety of surgical management strategies. Also, those who underwent irEVAR had had less severe preoperative anatomy and improved early outcomes.