Article

Outcomes of endovascular abdominal aortic aneurysm repair compared with open surgical repair in high-risk patients: Results from the Swedish Vascular Registry

Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden.
Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter (Impact Factor: 2.98). 10/2008; 48(6):1382-8; discussion 1388-9. DOI: 10.1016/j.jvs.2008.07.009
Source: PubMed

ABSTRACT The management of infrarenal aortic aneurysms in high-risk patients remains a challenge. Endovascular aneurysm repair (EVAR) is associated with superior short-term mortality rates but unclear long-term results and has not been shown to improve survival in patients unfit for open repair (OR). The aim of this population-based study was to evaluate the outcome after elective EVAR compared with OR in a high-risk patient cohort.
Prospectively collected data from January 2000 to December 2006 were retrieved from the Swedish Vascular Registry. The high-risk cohort was defined as age >or=60 years, American Anesthesiologists Association (ASA) class 3 or 4, and at least one cardiac, pulmonary, or renal comorbidity. These criteria were met by 217 of 1000 EVAR patients and 483 of 2831 OR patients. Primary end points were 30-day and 1-year all-cause mortality. Kaplan-Meier curves for survival and multivariate Cox regression analyses were performed.
The crude 30-day and 1-year all-cause mortality rates for EVAR vs OR for the whole treatment group (n = 3831) were 1.8% vs 2.8% and 8.0% vs 7.2%, respectively. In the high-risk cohort (n = 700), EVAR patients were approximately 2 years older and renal insufficiency and diabetes mellitus were more common, and smoking was more prevalent in the OR group. About two-thirds of EVAR procedures were performed at university hospitals and one-half of OR procedures were performed at county hospitals. In the high-risk cohort, there was no difference in mortality at 30-days (EVAR, 4.6% vs OR, 3.3%), but OR had lower 1-year mortality (8.5% vs 15.9%; P = .003). More bleeding complications occurred in the EVAR group, but more pulmonary complications occurred in the OR group; however, there was no difference in cardiac, cerebrovascular, or renal complications. The mean follow-up was 3.4 years. EVAR was associated with increased mortality risk after adjusting for age, ASA class, and comorbidities (hazard ratio, 1.50; 95% confidence interval, 1.07-2.12; P = .02). Kaplan-Meier survival analysis showed a lower mortality rate for patients undergoing OR, which remained during follow-up (P = .001).
Elective OR of aortic aneurysms seems to have a better outcome compared with EVAR in this specific, population-based, high-risk patient cohort after adjusting for covariates. We cannot confirm the benefit of EVAR from previous registry studies with a similar high-risk definition. In clinical practice, OR may be at least as good as EVAR in high-risk patients fit for surgery.

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Available from: Jonas Malmstedt, Jun 03, 2015
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    ABSTRACT: Background.We evaluated the incidence of mortality and myocardial infarction (MI) in endovascular repair (EVAR) as compared to open aneurysm repair (OAR) in both elective and ruptured abdominal aortic aneurysm (AAA ) setting. Methods. We analyzed the rates of 30-day mortality, 30-day MI, and hospital length of stay (LOS) based on comparative observation and randomized control trials involving EVAR and OAR. Results. 41 trials compared EVAR to OAR with a total pooled population of 37,781 patients. Analysis of elective and ruptured AAA repair favored EVAR with respect to 30-day mortality with a pooled odds ratio of 0.19 (95% CI 0.17–0.20; 𝐼 2 = 88.9%; 𝑃 < 0.001).There were a total of 1,835 30-day MI events reported in the EVAR group as compared to 2,483 events in the OAR group.The pooled odds ratio for elective AAA was 0.74 (95% CI 0.58–0.96; 𝑃 = 0.02) in favor of EVAR. The average LOS was reduced by 296.75 hrs (95% CI 156.68–436.82 hrs; 𝑃 < 0.001) in the EVAR population. Conclusions. EVAR has lower rates of 30-day mortality, 30-day MI, and LOS in both elective and ruptured AAA repair.
    04/2014; 2014(12). DOI:10.1155/2014/149243
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    ABSTRACT: BACKGROUND: Abdominal aortic aneurysm (AAA) affects approximately 5% of males over the age of 65. Open aneurysm repair (OAR) has been performed since the 1950s, however, the performance of endovascular repair (EVAR) of both elective and ruptured AAA has steadily increased. We aimed to evaluate the incidence of mortality and myocardial infarction (MI) in both endovascular and open approach to elective and ruptured AAA repair. METHODS: Systemic review and meta-analysis of observational and randomized clinical trials published prior to Jul 2012 where two reviewers independently conducted the literature search utilizing Medline, Embasse, Cochrane databases. We analyzed the rates of 30-day mortality, 30-day myocardial infarction, and hospital length of stay based on comparative observational and randomized control trials involving endovascular and open approach to elective and ruptured AAA repair. RESULTS: Overall, 41 trials compared EVAR to OAR with a total population of 37,781 patients. Analysis of 30-day mortality in elective and rAAA repair favored EVAR (OR 0.19, 95% CI 0.17-0.20, I2 = 88.9%, p <0.001). The pooled odds ratio for 30-day mortality for elective AAA was 0.74 (95% CI 0.58-0.96, p=0.02) favoring EVAR and 0.61 (95% CI 0.36-1.02, p=0.06) in patients with ruptured AAA. Twenty-nine trials of elective and 9 rAAA repair trials were included in the analysis of MI. There were a total of 1,835 events (1,806 events in the elective repair group) reported in the EVAR group compared with 2,483 events (2,388 events in the elective repair group) in the OAR group. The pooled odds ratio for elective AAA was 0.74 (95% CI 0.58-0.96, p=0.02) in favor of EVAR. Ruptured AAA was 0.61 (95% CI 0.36-1.02, p=0.06) suggesting a trend in favor of EVAR. The average decrease in length of stay was 296.75 hrs (95% CI 156.68-436.82 hrs, p<0.001) in the EVAR group when compared to open repair. CONCLUSIONS: The available data demonstrate that EVAR has lower rates of 30-day mortality, 30-day myocardial infarction, and hospital length of stay based on comparative observation and randomized control trials involving endovascular and open approach to elective and ruptured AAA repair.
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