Long-term Mortality and Reinterventions Following Repair of Ruptured Abdominal Aortic Aneurysms Using Vascular Quality Initiative Matched Medicare Claims

Abstract

The optimal treatment modality for ruptured infrarenal abdominal aortic aneurysm (rAAA) repair remains debated. This study sought to evaluate the impact of treatment type on long-term mortality and reintervention after rAAA repair in the Vascular Quality Initiative (VQI) registry. VQI (2004-2018) rAAA repairs were matched with eligible Medicare claims data. The primary outcome was long-term survival. Secondary outcomes were reintervention rates and the impact of receiving a reintervention on survival. Inverse probability weighting was used to adjust for treatment selection. Marginal Cox proportional hazards models were used to compare survival and marginal negative binomial regressions were used to compare the rate of reintervention between groups. Additional landmark analysis at hospital discharge was used owing to high perioperative mortality. Among 1885 VQI/Medicare rAAA patients, 790 underwent open aortic repair (OAR) and 1095 underwent EVAR. Median age was 76 years and 73% were male. Inverse probability weighting produced comparable groups for analysis. In hospital mortality was lower for EVAR (21% vs 36%; odds ratio [OR], 0.52; 95% confidence interval [CI], 0.4-0.7). Crude mortality at 1, 2, and 5 years For OAR versus EVAR was 48% versus 40%, 54% versus 48%, and 71 versus 63%, respectively (Figure). Mortality within 1 year was lower for EVAR versus OAR (hazard ratio [HR], 0.74; 95% CI, 0.6-0.9), but similar after 1 year (HR, 0.95; 95% CI, 0.8-1.2) (Table). Compared with OAR, reintervention rates were higher after EVAR at 2 and 5 years (risk ratio, 1.8 [95% CI, 1.2-2.7] and risk ratio, 2.0 [95% CI, 1.4-3.0]), but not within the first year. Receiving a reintervention was associated with higher mortality risk for both OAR (HR, 1.66; 95% CI, 1.1-2.5) and EVAR (HR, 2.14; 95% CI, 1.6-2.9). When excluding in-hospital deaths, long-term mortality was similar between repair types (HR, 0.99; 95% CI, 0.8-1.2). The result of reinterventions and their impact on mortality was unchanged in landmark analysis. Within the VQI/Medicare patients undergoing rAAA repair, the perioperative benefit of EVAR dissipated after 1 year. Reintervention rates are more common after EVAR and are associated with higher mortality despite repair modality. These data highlight the need to improve long-term treatment after rAAA and to better define high-risk groups for reintervention.TableOverall mortality of open aneurysm repair (OAR) versus endovascular aneurysm repair (EVAR)MortalityOAREVARP valueIn-hospital Count (%), unweighted288 (36.46)233 (21.28)<.001 Odds ratio (95% CI)UnweightedRef0.47 (0.38-0.58)<.001WeightedRef0.52 (0.41-0.67)<.001 Hazard ratio (95% CI)Unweighted≤1 yearRef0.73 (0.63-0.84)<.001>1 yearRef0.95 (0.76-1.18)Not significantWeighted≤1 yearRef0.74 (0.63-0.87)<.01>1 yearRef0.95 (0.75-1.20)Not significantCI, confidence interval. Open table in a new tab