EVAR yields lower morbidity rates, shorter length of stay vs. open aortic repair
Endovascular aortic aneurysm repair is not associated with a difference in mortality rates vs. open aortic repair, although it appears to yield a significantly lower overall rate of morbidity and ICU/hospital length of stay, according to recent findings.
In the propensity-matched analysis, researchers reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database’s public use file from 2012 to 2015 to identify 1,005 open or endoluminal aneurysm repairs (789 juxtarenal aortic aneurysms and 216 pararenal aortic aneurysms).
For this study, juxtarenal aortic aneurysms were defined as those approaching the renal artery aneurysm, and pararenal aortic aneurysms were those that involved the renal artery origin. The following procedure-targeted variables were also included: type of main body graft used, type of vascular access, use of a conduit, method if hypogastric management, use if an iliac branched device, use of renal stents, and use of aortic iliac bare-metal stents. Open-repair variables studied included surgical approach and proximal clamp location.
Outcomes of interest
The researchers assessed the following 30-day outcomes: mortality and composite morbidity (one or more of 21 adverse events as defined by the ACS-NSQIP), as well as the following: need for transfusion within 72 hours of surgery, return to the operating room within 30 days, readmission within 30 days, postoperative cardiac or respiratory failure, surgical site infection or dehiscence, renal insufficiency or failure, pneumonia, sepsis or septic shock, and treatment for deep vein thrombosis or pulmonary embolism.
Propensity scoring yielded a matched cohort of 263 endovascular and 263 open aortic repairs. The matched groups were then compared for outcomes.
The researchers found that preoperative patient characteristics before propensity matching showed a higher prevalence of the following characteristics in the EVAR group vs. the open aortic repair group: older age (mean, 75.3 vs. 71.7 years; P < .001), a higher proportion of patients with bleeding disorders (15.7% vs. 7.9%; P < .001) and a higher rate of patients with preoperative kidney failure or dialysis dependency (4.6% vs. 0.8%; P < .001).
Before propensity matching, preoperative patients slated to undergo open aortic repair were more likely to be American Society of Anesthesiology class IV (29.1% vs. 37.9%; P < .016) and to be current smokers (33.7% vs. 48.4%; P < .001).
At 30 days, propensity-matched postoperative outcome analysis found no statistically significant difference in 30-day mortality between open-repair and EVAR patients (2.7 vs. 5.7). Median ICU length of stay was lower in the EVAR group (0 days; interquartile range [IQR], 0-1 days) vs. that of the open aortic repair group (3 days; IQR, 1-5 days; P < .001), as was median hospital length of stay (EVAR group: 2 days; IQR, 1-5 days; open aortic repair group: 8 days; IQR, 6-11 days; P < .001).
Morbidity benefit
There was a lower rate of 30-day morbidity for EVAR vs. open repair (16% vs. 35%; P < .001). This lower morbidity rate was attributable to lower rates of the following variables: return to OR (6.8% vs. 15%; P = .005), cardiac/respiratory failure (7.6% vs. 21%; P < .001), kidney insufficiency or failure (3.8% vs. 9.9%; P = .009) and pneumonia (1.5% vs. 6.8%; P = .004).
The EVAR group had lower rates of transfusion, the researchers wrote.
“Our results comparing the 30-day outcomes of EVAR vs. [open aortic repair] for [juxtarenal aortic aneurysms/pararenal aortic aneurysms] showed no difference in mortality but did show a significant difference in overall morbidity, ICU [length of stay] and hospital [length of stay] favoring EVAR over [open aortic repair],” the researchers wrote. “Although open aortic surgery remains an essential treatment option for the repair of [juxtarenal aortic aneurysms/pararenal aortic aneurysms], these data add to the growing body of literature showing the safety and efficacy.” – by Jennifer Byrne
Disclosure: The researchers report no relevant financial disclosures.
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