Improved Long-Term Survival After Abdominal Aortic Aneurysm Repair

Abstract

Conclusion: Despite a change in case-mix toward older patients with increased comorbidity, long-term survival after repair of an intact abdominal aortic aneurysm (AAA) has improved over time and has remained stable after ruptured AAA repair. Summary: This article is an analysis of data from the Swedish Vascular Registry. During the time of this analysis, the incidence of intact AAA repair in Sweden increased significantly, whereas the incidence of ruptured AAA repair did not change. Overall, however, it appears mortality may be decreasing for both intact and ruptured AAA repair (Br J Surg 2008;95:564-70). Improved short-term survival combined with increasing age of patients treated for AAA could potentially result in a reduction of long-term survival. The authors therefore analyzed long-term crude and relative survival after AAA repair in Sweden during an 18-year period from 1987 to 2005. During the study period, 8663 primary intact and 4171 ruptured AAA repairs were recorded in the Swedish Vascular Registry. Mortality was determined from the national population registry. Crude survival was analyzed. Also analyzed was relative survival, being the survival rate of patients compared with that of the general population adjusted for age, sex, and calendar year, excluding 90-day mortality. When AAA repairs from 1987 to 1999 were compared with those from 2000 to 2005, patient age increased from 71.4 to 72.2 years (P < .001), the percent of patients with comorbidities increased from 65.5% to 68.5% (P < .001), and use of endovascular repair increased from 1.6% to 17.0% (P < .001). Crude 5-year survival after intact AAA repair was 69.0% (99% confidence interval [CI], 67.7%-70.4%). Relative 5-year survival, excluding 90-day mortality, was 90.3% (99% CI, 88.6%-92.0%). For those who underwent operations from 2000 to 2005, relative survival was better compared with those who underwent operations from 1987 to 1999 (difference 4.7%; 99% CI, 1.3%-8.1%). Relative survival was also better for men vs women (difference, 4.6%; 99% CI, 0.4%-8.8%). No difference was observed between open and endovascular repair (6%, 99% CI, −1.5% to 13.4%). After ruptured AAA repair, the crude 5-year survival was 41.7% (99% CI, 39.6%-43.7%) and relative survival was 87.1% (99% CI, 83.9%-90.3%). No differences in relative 5-year survival were observed between time period, sex, or age groups. Comment: The data indicate AAA repair is an effective operation for prolonging survival, although certainly repair of an AAA does not appear to return the patients to a normal expected survival compared with age- and sex-matched controls without an AAA. Further improvements in long-term survival after AAA repair will likely be primarily based on better medical management of patients with vascular disease. The challenge will be to do this in a cohort of patients of increasing age and increasing comorbidities.