The Impact Associated with Changing Practice Patterns for the Treatment of Abdominal Aortic Aneurysms in the United States

Abstract

We have witnessed an evolution in the treatment of abdominal aortic aneurysm (AAA) from open to endovascular repair. The implications that these changes have had on outcomes, have not been thoroughly studied. We evaluated the trends in volume of open and endovascular AAA repairs done nationwide in a recent 20-year period, and the outcomes associated with each type of repair, to assess how outcomes may have changed over this period. Patients with AAA undergoing elective open and endovascular repair between 2000 and 2020 were identified using the TriNetX Analytics Network, a federated network of nationwide healthcare organizations that provides deidentified patient data. Patients undergoing first-time elective endovascular or open AAA repair (infrarenal and visceral) from 2001 to 2020 were separated, plotted over time, and propensity score matched. Primary outcome was mortality; secondary outcomes included myocardial infarction (MI), pneumonia and acute kidney injury (AKI). Over the 20-year period we identified 21,368 endovascular patients and 6473 open patients. The endovascular volume surpassed open volume between 2004 and 2005 and we saw a steady increase in endovascular repairs (Fig 1). From 2001 to 2010, mortality was 2.35% for open and 0.98% for endovascular (P < .001); MI was 1.40% for open and 0.90% for endovascular (P = .0004); pneumonia was 2.77% for open and 1.03% for endovascular (P < .001); and AKI was 1.85% for open and 0.91% for endovascular (P = .0014). From 2011 to 2020 mortality was 5.07% for open and 3.89% for endovascular (P = .09); MI was 2.48% for open and 2.39% for endovascular (P = .375); pneumonia was 4.21% for open and 3.10% for endovascular (P = .02); and AKI was 6.53% for open and 4.65% for endovascular (P = .07). When mortality was plotted over time for endovascular and open repairs they both increased (Fig 2). With respect to open repairs the mortality for infrarenal AAA increased from 2001 to 2010 by 2.07% and from 2011 to 2020 by 16.20% (P = .004); visceral AAA increased from 2001 to 2010 by 5.45% and from 2010 to 2020 by 15.73% (P = .016). Endovascular AAA repair has steadily increased over time, while open repair decreased and subsequently increased to a steady state over the recent 20-year period. It appears our mortality has increased for both endovascular and open repair types despite our increased exposure to endovascular cases in practice. Mortality for endovascular repair was significantly higher from 2000 to 2009, but not for 2010 to 2020. Mortality increased significantly from the first decade for both infrarenal and visceral aneurysms.