Increasing Mortality Trends for Open Infrarenal and Thoracoabdominal Aneurysm Repairs in the Endovascular Era

Abstract

Rapid adoption of endovascular aneurysm repair (EVAR) has been driven by improving trends in perioperative morbidity and mortality compared with open repair. Perioperative outcomes in the current era of anatomically more complex open repairs remain undetermined. The purpose of this study was to investigate trends for elective and ruptured aneurysm repairs and in-hospital mortality for these patients at a high-volume tertiary care, university teaching hospital. This study used an institutional, prospectively maintained database that derives all data from electronic hospital records, billing data, and patient charts to capture patients receiving either EVAR or open repair for abdominal aortic aneurysm (AAAs) and thoracoabdominal aortic aneurysms during an 11-year period between January 2004 and January 2015. There were 2753 aneurysm repairs performed throughout the study period; 1673 (60.1%) were open repairs, whereas 1080 (39.2%) were EVAR. In 2004, 29 EVARs were performed (14.9% of total aneurysm repairs), increasing to 110 repairs in 2014 (46.8%; Fig 1). Linear regression demonstrated an 11-year average increase in EVAR of 10.5 cases per year (R2 = 0.68), whereas open repair decreased by 5.2 cases per year (R2 = 0.73). Percentage of ruptured AAA repairs decreased from 11.3% in 2004 to 6.0% in 2014 with an increasing proportion performed by EVAR (9.1% in 2004 and 35.7% in 2014). Mortality for EVAR decreased from 6.9% in 2004 to 0.9% in 2014, whereas open repair mortality increased from 2.4% in 2004 to 6.4% in 2014 (Fig 2). Respectively, average mortality for elective EVAR and open repair was 3.5% and 2.7% from 2004 to 2007, 0.9% and 1.8% from 2008 to 2011, and 1.6% and 5.6% from 2012 to 2014. There is an ongoing transition favoring EVAR over open repair in the management of AAAs and thoracoabdominal aortic aneurysms, albeit a slower rate of adoption at our center. Notably, there is an evident trend toward increasing mortality among patients receiving open repair. We postulate increasing patient complexity and possibly decreased institutional memory (factors related to surgeon, anesthesia, and intensive care unit experience) in the era of increasing endovascular and diminishing open repairs.Fig 2Mortality rate for intact abdominal aortic aneurysms (AAAs) by procedure type and overall combined mortality.View Large Image Figure ViewerDownload Hi-res image Download (PPT)