Comparison of Long-term Survival After Open vs Endovascular Repair of Intact Abdominal Aortic Aneurysm Among Medicare Beneficiaries

Abstract

Context Endovascular repair of abdominal aortic aneurysm (AAA) compared with open repair increases perioperative survival, but it is not known if it increases long-term survival. Objective To compare long-term outcomes after open vs endovascular repair of AAA. Design, Setting, and Patients Retrospective analysis of patients 65 years or older in the Medicare Standard Analytic File, 2003-2007, who underwent isolated repair of intact AAA. Cause of death was determined from the National Death Index. Main Outcome Measures The primary outcome was all-cause mortality. Secondary outcomes were AAA-related mortality, hospital length of stay, 1-year readmission, repeat AAA repair, incisional hernia repair, and lower extremity amputation. Results Of 4529 included patients, 703 were classified as having undergone open repair and 3826 as having undergone endovascular repair. Mean and median follow-up times were 2.6 (SD, 1.5) and 2.5 (interquartile range, 2.4) years, respectively. In unadjusted analysis, both all-cause mortality (173 vs 752; 89 vs 76/1000 person-years, P = .04) and AAA-specific mortality (22 vs 28; 11.3 vs 2.8/1000 person-years, P < .001) were higher after open vs endovascular repair. After adjusting for emergency admission, age, calendar year, sex, race, and comorbidities, there was a higher risk of both all-cause mortality (hazard ratio [HR], 1.24 [95% CI, 1.05-1.47]; P = .01) and AAA-related mortality (HR, 4.37 [95% CI, 2.51-7.66]; P < .001) after open vs endovascular repair. The adjusted hospital length of stay was, on average, 6.5 days (95% CI, 6.0-7.0 days, P < .001) longer after open repair (mean, 10.4 days), compared with endovascular repair (mean, 3.6 days). Incidence of incisional hernia repair was higher after open AAA repair (19 vs 23; 12 vs 3 per 1000 person-years; adjusted HR, 4.45 [95% CI, 2.37-8.34, P < .001]), whereas the incidence of 1-year readmission (188 vs 1070; 274 vs 376/1000 person-years; adjusted HR, 0.96 [95% CI, 0.85-1.09, P = .52]), repeat AAA repair (15 vs 93; 9.7 vs 12.3/1000 person-years; adjusted HR, 0.80 [95% CI, 0.46-1.38, P = .42]), and lower extremity amputation (3 vs 25; 1.9 vs 3.3/1000 person-years; adjusted HR, 0.55 [95% CI, 0.16-1.86, P = .34]) did not differ by repair type. Conclusion Among older patients with isolated intact AAA, use of open repair compared with endovascular repair was associated with increased risk of all-cause mortality and AAA-related mortality.