Treatment Outcome Trends for Non-Ruptured Abdominal Aortic Aneurysms: A Nationwide Prospective Cohort Study

Anna J Alberga,J.K Kievit,P.T Den Hoed,J.H Nederhoed,Jan J Wever,H.J Smeets,E.F.A De Haan,G.A Vos,C.J.J.M Sikkink,P.J Van Den Akker,J.E Dierikx,Robert H Geelkerken,Hence J.M Verhagen,C Van Der Waal,C.J Van Vlijmen - Van Keulen,A.M Avontuur,M.E Bodegom,H.W Palamba,D Nio,R.P Tutein Nolthenius,L Van Der Laan,I Dawson,A.C De Vries,M.K Dinkelman,E.S Van Hattum,R.R Kruse,M.C Loubert,F.T.H.P.M Van Der Linden,S.E Buijk,M.G Van Andringa De Kempenaer,R.H.W Van De Mortel,T.M Smits,R.A Stokmans,A Rijbroek,A.O Sondakh,L.M.C Van Dortmont,M.R Kapma,M.M Van Der Eb,Eleonora G Karthaus,R.J Hissink,A.P.M Boll,M Dirven,C.H.A Wittens,T.A Jongbloed-Winkel,A.S Bode,J.P.P.M De Vries,M.G Buimer,E.D Ponfoort,B.J Telgenkamp,G.S Van Eps,A.A.E.A De Smet,P.H Castenmiller,D.M Scharn,S.C De Jong,P.C Smit,W.B Barendregt,B.P Vierhout,Y.C.A Montauban Van Swijndregt,M.S Lemson,P.W.H.E Vriens,W.B Van Gent,P.M Schlejen,W.L Akkersdijk,N.A Koedam,R.B.M Van Tongeren,W.J Thijsse,C.G Manshanden,G.G Koning,J Nieuwenhuizen,R Meerwaldt,R.F.F Van Den Haak,S.K Nagesser,B.I Oranen,B.L Reichmann,M.E Witte,B.H.P Elsman,M.J Faber,M.G Samyn,P.M Van Schaik,D Eefting,B.M Wallis De Vries,B De Vos,A.M Nevenzel,A.C Vahl,J.A.M De Ridder,R.J Beuk,H.P Van ’T Sant,D.H Nieuwenhuis,R.H.J Kropman,E Tournoij,G Cazander,R.P.R Groenendijk,A Van Der Elst,J.L Van Wanroi,M Van Den Berg,M.J Speijers,P Brummel,Jorg L De Bruin,G.F Hajer,V Brehm,P.F Liqui Lung,A.G Peppelenbosch,G.J Glade,R.P Strating,M.G Veldman,T.J Van Der Steenhoven,J Diks,R.A De Roo,M De Vries,Jaap F Hamming,R.G Hulsebos,V.J Leijdekkers,W.T.G.J Bos-Van Rossum,L.G Van Der Hem,R.C Van Nieuwenhuizen,W.M De Fijter,H.C.J.L Buscher,K Türkcan,G.J.W.M Van Eijck,G.J Lauret,E.D Wilschut,R.M The,L.C Huisman,F Van Hoek,J.A Van Der Vliet,M.T.C Hoedt,J.P Van Brussel,B.L.S Borger Van Der Burg,M.e Pierie ,Wilbert M Fritschy ,Gijs M.j.m Welten ,Joep A.w Teijink ,Roel Janssen ,H.h Jiang ,Renske Konings ,C.c Naves ,F.p Schol ,Steven M.m Van Sterkenburg ,D.a Stigter ,Bram Fioole ,Ron Balm ,Mare M.a Lensvelt ,E.g Vermeulen ,Janneke Wilschut ,Dalia Mahmoud ,Ben R Saleem ,M.j Jacobs ,W.i Willaert ,A Vos ,Ozan Yazar ,Vincent Jongkind ,Marijke J Molegraaf ,Johanna M Hendriks ,P Poyck ,C.e Hazenberg ,Anliu Nie ,Chris Van Weel ,Vincent P W Scholtes ,Michel F Van Der Jagt ,W M C Mulder ,Roderik Metz ,Rigo Hoencamp ,M.j Testroote ,Maarten J Van Der Laan ,Marc R Scheltinga ,P Klinkert ,Guus W Van Lammeren ,Felix J.v Schlösser ,P.h Cuypers ,Sander Ten Raa ,Ellen V Rouwet ,Jozien Helleman ,J.m Botman ,Maarten A Lijkwan ,Jan Bosma ,Alex Ploeg ,Robert A Pol ,Raechel J Toorop ,Anna Prent ,J.t Raymakers ,Koen M Van De Luijtgaarden ,Theo P Menting ,B.h Vriens ,Olivier H.j Koning ,J C A De Mol Van Otterloo ,Bart‐Jeroen Petri ,Jan Wille ,Ernst Cancrinus ,Eelco J Veen ,Koen E.a Van Der Bogt ,Joost A Van Herwaarden ,J.l Kolkert ,G.n Stultiëns ,Penghui Jin ,Dennis E J G J Dolmans ,M I A Van Engeland ,Jan-Willem H P Lardenoije ,Michiel A Schreve ,Jan-Willem Hinnen ,B.p Keller ,A Khodadade Jahrome ,Peter Klemm ,Clark J Zeebregts ,B J M Leenders ,George P Akkersdijk ,J.e Sybrandy ,I.f Tielliu ,A.p Oomen ,Edward Hollander ,Johannes W Drouven ,Ckh Wong ,C.h Arts ,Monika Morak ,Hans G.w De Groot ,Gert J De Borst ,André S Van Petersen ,Marc R.h.m Van Sambeek ,Çağdaş Ünlü ,Jan Van Schaik ,Evert J Waasdorp ,Michiel C Warlé ,A Krasznai ,J.r Jansbeken ,Maarten Loos ,Joost R Van Der Vorst ,Cornelis G Vos ,M.j Visser ,M H Booster ,M.c Willems ,Maarten Truijers ,Bart A.n Verhoeven ,Dink A Legemate ,Michiel T Voûte ,Luuk Smeets ,Irene Thomassen ,Thanyalak Tha-In ,Mirza M Idu ,M.m Reijnen ,J H C Daemen ,Kak K Yeung ,E.c Mattens ,K.m Huntjens ,Jan D Blankensteijn ,B.l Bendermacher ,Lee H Bouwman ,Martijn Bruijn ,Marie Josee E Van Rijn ,Alexander Te Slaa ,Martijn Dijkstra ,Jorinde H.h Van Laanen ,Bastiaan Govaert ,Maarten Snoeijs ,De Vries ,O.r Wikkeling ,Werner H Hoffmann ,P.p Hedeman Joosten ,Christine Vermeulen ,Roel Vaes ,Abbey Schepers ,Rozemarijn J Van Der Vijver-Coppen ,M.j Koelemaij ,Geert Willem H Schurink ,Arno M Wiersema ,Gwan H Ho ,Olaf J Bakker ,Joost A Bekken ,Edith M Willigendael ,Barend Mees ,Jan M.m Heyligers ,R Smeets ,Jacques Oskam ,Willem Wisselink ,J.w Elshof ,Olaf Schouten ,Andrew Well ,Arjan W.j Hoksbergen ,D.a Lamprou ,Laurens A Van Walraven ,Mart Bender ,Hugo T.c Veger ,Michiel L.p Van Zeeland

doi:10.1016/j.ejvs.2021.08.019

Abstract

<h3>Objective</h3> The Dutch Surgical Aneurysm Audit (DSAA) initiative was established in 2013 to monitor and improve nationwide outcomes of aortic aneurysm surgery. The objective of this study was to examine whether outcomes of surgery for intact abdominal aortic aneurysms (iAAA) have improved over time. <h3>Methods</h3> Patients who underwent primary repair of an iAAA by standard endovascular (EVAR) or open surgical repair (OSR) between 2014 and 2019 were selected from the DSAA for inclusion. The primary outcome was peri-operative mortality trend per year, stratified by OSR and EVAR. Secondary outcomes were trends per year in major complications, textbook outcome (TbO), and characteristics of treated patients. The trends per year were evaluated and reported in odds ratios per year. <h3>Results</h3> In this study, 11 624 patients (74.8%) underwent EVAR and 3 908 patients (25.2%) underwent OSR. For EVAR, after adjustment for confounding factors, there was no improvement in peri-operative mortality (aOR [adjusted odds ratio] 1.06, 95% CI 0.94 – 1.20), while major complications decreased (2014: 10.1%, 2019: 7.0%; aOR 0.91, 95% CI 0.88 – 0.95) and the TbO rate increased (2014: 68.1%, 2019: 80.9%; aOR 1.13, 95% CI 1.10 – 1.16). For OSR, the peri-operative mortality decreased (2014: 6.1%, 2019: 4.6%; aOR 0.89, 95% CI 0.82 – 0.98), as well as major complications (2014: 28.6%, 2019: 23.3%; aOR 0.95, 95% CI 0.91 – 0.99). Furthermore, the proportion of TbO increased (2014: 49.1%, 2019: 58.3%; aOR 1.05, 95% CI 1.01 – 1.10). In both the EVAR and OSR group, the proportion of patients with cardiac comorbidity increased. <h3>Conclusion</h3> Since the establishment of this nationwide quality improvement initiative (DSAA), all outcomes of iAAA repair following EVAR and OSR have improved, except for peri-operative mortality following EVAR which remained unchanged.

Highlights

As a result of endovascular aneurysm repair (EVAR), the management of intact abdominal aortic aneurysms has changed dramatically in the last decades resulting in improved peri-operative outcomes.[1]
Since the first EVAR was performed in the 1990s, many patients with suitable anatomy have received EVAR rather than open surgical repair (OSR) because of the lower peri-operative risks of EVAR,[2] with a subsequent decrease in the number of patients treated by OSR.2e5 frail patients can receive EVAR rather than conservative treatment.[6]
15 562 patients treated in 61 hospitals underwent EVAR or OSR for a primary intact abdominal aortic aneurysms (iAAA), of whom 15 532 (99.8%) were eligible (2 445 - 2 753 patients per year) and 30 (0.2%) were excluded (Fig. 1)

Summary

Introduction

As a result of endovascular aneurysm repair (EVAR), the management of intact abdominal aortic aneurysms (iAAA) has changed dramatically in the last decades resulting in improved peri-operative outcomes.[1] Since the first EVAR was performed in the 1990s, many patients with suitable anatomy have received EVAR rather than open surgical repair (OSR) because of the lower peri-operative risks of EVAR,[2] with a subsequent decrease in the number of patients treated by OSR.2e5 frail patients can receive EVAR rather than conservative treatment.[6] These changes in treatment strategy probably have resulted in fewer OSRs per hospital, which may have negatively influenced the outcomes of OSR.[7]. A study of an international cohort of vascular registries that described trends in the management and outcomes of iAAA repair from 2005 up to 2013 reported an overall decrease of peri-operative mortality from 3.0% to 2.4% while the peri-operative mortality after OSR increased from 3.9% to 4.4%.8. No studies have examined the most recent trends in the management and outcomes of iAAA repair, reflecting real world nationwide data

Methods

Results

Conclusion