Invited commentary

Abstract

This study is a retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) vascular module database. The authors compared the 30-day reintervention and mortality rates after endovascular aneurysm repair (EVAR) and open repair for 5877 abdominal aortic aneurysms (AAAs). Surprisingly, the 30-day reintervention rate was higher after open repair than after EVAR. Also, reintervention was associated with a 12 times higher mortality after either procedure. There have been a number of large-scale randomized controlled trials comparing open repair vs EVAR, but most are outdated and have not investigated the 30-day reintervention rate and its impact on mortality; therefore, this study provides valuable and updated information. In this study, even though the authors have selected only infrarenal AAA and have not included juxtarenal and pararenal AAAs, and although the open group patients were younger than the EVAR group, it is likely that the open group consisted of AAAs including those with shorter proximal neck, concomitant aortoiliac occlusive disease, shaggy aorta, and angulated anatomy, all of which make EVAR difficult. Because of this selection bias, it is likely that the open group consisted of more difficult AAAs, and this probably affected the poor outcome in the open group. Having said that, and despite these shortcomings, I believe that this study is bright news for EVAR technology, for which confidence had somewhat been lost following publication of the long-term results of the EVAR 1 trial.1Patel R. Sweeting M.J. Powell J.T. Greenhalgh R.M. EVAR trial investigatorsEndovascular versus open repair of abdominal aortic aneurysm in 15-years' follow-up of the UK endovascular aneurysm repair trial 1 (EVAR trial 1): a randomized controlled trial.Lancet. 2016; 388: 2366-2374Abstract Full Text Full Text PDF PubMed Scopus (600) Google Scholar The current study confirms that with modern devices and improved techniques, EVAR can be performed with extremely low mortality, open conversion, and early reintervention rate. On the contrary, this study showed an alarmingly high reoperation rate after open repair, even considering the aforementioned selection bias. This may be due to deterioration of open AAA repair training and performance, something that we have been concerned about since EVAR became the first-line treatment and the number of open repairs decreased dramatically. This alarming finding has been confirmed in a recent international study, and this observation appears to be real.2Budtz-Lilly J. Venermo M. Debus S. Behrendt C.A. Altreuther M. Beiles B. et al.Assessment of international outcomes of intact abdominal aortic aneurysm repair over 9 years.Eur J Vasc Endovasc Surg. 2017; 54: 13-20Abstract Full Text Full Text PDF PubMed Scopus (86) Google Scholar The study also showed that reoperation was higher in patients who underwent open repair, those who had larger AAAs, and those with hypertension and chronic kidney disease. These data should be considered to further improve the care of AAAs, which is exactly the goal of the NSQIP program. In summary, although this study is retrospective and nonrandomized and suffers from selection bias, it represents modern AAA practice in the United States and shows progressively improving EVAR outcome and, on the contrary, dwindling and deteriorating open repair, something that the vascular surgeons need to take seriously. I would like to thank the NSQIP program and the authors for providing us valuable information that has pointed out what we need to do to improve the overall care of AAAs. The opinions or views expressed in this commentary are those of the authors and do not necessarily reflect the opinions or recommendations of the Journal of Vascular Surgery or the Society for Vascular Surgery. Early reintervention after open and endovascular abdominal aortic aneurysm repair is associated with high mortalityJournal of Vascular SurgeryVol. 67Issue 2PreviewAlthough reinterventions are generally considered more common after endovascular aneurysm repair (EVAR) than after open surgical repair (OSR), less is known about reintervention in the early postoperative period. Furthermore, there are few data regarding the impact of early reintervention on 30-day mortality. We sought to evaluate the rates and types of reintervention after abdominal aortic aneurysm (AAA) repair and the impact of reintervention on postoperative mortality. Full-Text PDF Open Archive