Invited commentary

Abstract

This article presents important information on trends in both elective and ruptured abdominal aortic aneurysm (AAA) repair and its associated mortality in the United States Medicare population. The number of procedures performed in this population is declining, despite the increasing size of the population >65 years of age. Importantly, significant decreases in mortality after elective AAA repair occurred during this period, indicating improvements in care of both men and women. The benefits of these improvements have not been equally distributed between the sexes. The decline in elective and ruptured AAA (RAAA) mortality for men is greater than that observed for women; however, women are older when they undergo operative repair. Women have a higher chance of presenting as a rupture, a lower incidence of attempted repair, and a higher mortality rate. A key finding in this study is that the RAAA mortality rate has not declined; however, the incidence of RAAA appears to have declined. Overall, the population aneurysm-related mortality is significantly influenced by the excessive RAAA mortality. This highlights the importance of AAA identification through screening, which can have a significant impact in reducing the aneurysm-related mortality. Continued efforts to reduce the mortality of elective AAA repair will also have a significant population impact. The acknowledged limitation of this database is that it captures only those aged ≥65, therefore eliminating 15% to 25% of United States AAA repairs. The lack of information about younger patients may result in an overestimation of the true population-based perioperative mortality rate. This difference is likely to be larger for men than for women because women develop aneurysms at an older age. The article highlights key areas where the profession must advocate on behalf of patients and identifies areas that require further study to reduce aneurysm-related mortality at the population level. First, implementing evidence-based screening programs is critical to identify patients with asymptomatic aneurysms to further reduce the incidence of RAAA and offer elective repair. Studies of women are warranted to determine if AAA screening is beneficial and to identify a female size threshold for repair. Second, research into the pathophysiology of organ injury after RAAA repair is important to develop approaches to reduce postoperative morbidity and mortality. Third, the impact of endovascular aneurysm repair (EVAR) on AAA mortality is just beginning to be identified in this population and will become clearer with ongoing surveillance. EVAR has been proven to reduce 30-day mortality and 4-year aneurysm-related mortality. The increasing application of EVAR to RAAA may be the first major advance to decrease the mortality associated with this condition in 55 years. This article does identify important progress in the treatment of abdominal aneurysms over the last decade, and it highlights that the benefits of progress have not been shared equally between the sexes.