“The relative survival benefit of EVAR over open repair has increased over time,” conclude Rens RB Varkevisser (Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA) and colleagues in the July edition of the Journal of Vascular Surgery (JVS). This conclusion was based on a retrospective review of Society for Vascular Surgery (SVS) Vascular Quality Initiative (VQI) data that show five-year survival after endovascular aneurysm repair (EVAR) for ruptured abdominal aortic aneurysms (AAA) has improved over time, whereas survival after open repair has remained constant.
The authors note that increasing experience and improving technology have led to the expansion of EVAR for ruptured AAA. Therefore, they set out to investigate whether the five-year survival after both EVAR and open repair for ruptured AAA has changed over the last 14 years.
Varkeivisser et al identified repairs for ruptured infrarenal AAA within the VQI registry between 2004 and 2018 and compared five-year survival of both EVAR and open repair between the early (2004–2012) and late (2013–2018) cohorts.
Within the 2004–2018 VQI database, they identified 4,638 ruptured AAA repairs, which included 409 EVARs in the early cohort and 2,250 in the late cohort, as well as 558 open repairs in the early cohort and 1,421 in the late cohort.
The authors report that propensity matching resulted in 366 matched pairs of late versus early EVAR and 391 matched-pairs of late versus early open repair. When comparing EVAR with open repair, propensity matching resulted in 277 matched pairs of early EVAR versus open, and 1,117 matched pairs of late EVAR versus open.
In matched EVAR patients, five-year survival was higher in the late cohort (63% vs. 49%; hazard ratio [HR], 0.77; 95% confidence interval [CI], 0.61–0.97; p=0.027), whereas there was no difference between matched late versus early for open repair patients (52% vs. 59%; HR, 1.04; 95% CI, 0.85–1.28; p=0.69).
In the early cohort, there was no survival difference between EVAR and open repair (51% vs. 46%; HR, 0.88; 95% CI, 0.69–1.11; p=0.28). However, in the late cohort EVAR was associated with higher survival compared with open repair (63% vs. 54%; HR, 0.69; 95% CI, 0.6–0.79; p=0.001).
Varkeivisser and colleagues caution that the findings from this study should be interpreted in the context of the study design. “This was a retrospective analysis and therefore could not adjust for decisions based on certain anatomic restrictions, making it likely that at least some of the open repairs would not have been candidates for EVAR,” they detail.
They also address the fact that this study only investigates midterm outcomes. “Both the rate of late adverse outcomes other than mortality, as well as the outcomes after five years, should be subject to further investigation,” they remark. Furthermore, the investigators acknowledge that they were unable to study whether surveillance regimens after EVAR improved over time and how surveillance impacted their outcomes.