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Updated: Jun 10, 2025
A New Murine Model of Endovascular Aortic Aneurysm Repair
Published on: July 7, 2013
Comparison of open and endovascular repair of complex abdominal aortic aneurysms
Sai Divya Yadavalli1, Vinamr Rastogi2, Ambar Mehta3
1Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
Insights
Endovascular repair (FEVAR) offers lower perioperative mortality for complex abdominal aortic aneurysms (cAAA) in males but shows similar short-term outcomes in females. Long-term, FEVAR in females leads to higher reintervention and mortality rates compared to open repair (OAR).
Area of Science:
- Vascular Surgery
- Endovascular Interventions
- Aortic Aneurysm Repair
Background:
- Complex abdominal aortic aneurysms (cAAAs) require careful consideration of repair strategies.
- Sex-based differences in outcomes after aortic aneurysm repair are increasingly recognized.
- Endovascular aneurysm repair (EVAR) and open surgical repair (OSR) are primary treatment options.
Purpose of the Study:
- To compare perioperative and 5-year outcomes of fenestrated endovascular aortic repair (FEVAR) versus open repair (OAR) for cAAAs.
- To analyze outcomes separately in males and females to identify sex-specific differences.
- To inform clinical decision-making and future research directions for cAAA treatment.
Main Methods:
- Analysis of elective cAAA repairs from the VISION registry (2014-2019).
- Stratification of patients by sex and propensity score matching for OAR versus FEVAR.
- Evaluation of perioperative and 5-year outcomes (mortality, reintervention, rupture) using regression models.
Main Results:
- FEVAR demonstrated lower perioperative mortality in males, but 5-year outcomes were comparable with OAR, with higher reintervention rates.
- In females, FEVAR and OAR showed similar perioperative mortality.
- At 5 years, FEVAR in females was associated with higher mortality and reintervention rates compared to OAR.
Conclusions:
- FEVAR offers short-term benefits for male cAAA repair, but long-term advantages diminish.
- FEVAR in females shows no perioperative advantage and is linked to worse long-term outcomes (higher mortality and reintervention).
- Further research is needed to understand and address sex disparities in FEVAR outcomes, with cautious patient selection advised for females.
Objective:
The aim of this study was to compare perioperative and 5-year outcomes following endovascular (FEVAR) and open repair (OAR) of complex abdominal aortic aneurysms (cAAAs) in males and females separately, given the known sex-related differences in perioperative outcomes.
Methods:
We studied all elective cAAA repairs between 2014 and 2019 in the Vascular Implant Surveillance and Interventional Outcomes Network (VISION) registry. We stratified patients based on sex. We calculated propensity scores for assignment to either OAR or FEVAR. Covariates including age, race, diameter, baseline comorbidities, proximal extent of repair, annual center volumes, and annual surgeon volumes were introduced into the model for estimating propensity scores. Within matched cohorts, perioperative outcomes and 5-year outcomes (mortality, reinterventions, and ruptures) were evaluated using multivariable logistic and Cox regression models.
Results:
We identified 2825 patients, of whom 29% were female. Within both the sexes, OAR was more commonly performed (OAR vs FEVAR: males: 53% vs 47%; females: 63% vs 37%). After matching, among males (n = 1326), FEVAR was associated with lower perioperative mortality (FEVAR vs OAR: 2.3% vs 5.1%; P < .001). However, FEVAR was associated with comparable 5-year mortality (38% vs 28%; hazard ratio [HR], 1.2; 95% confidence interval [CI], 0.92-1.4; P = .22) and a higher hazard of 5-year reintervention (19% vs 3.7%; adjusted HR, 4.5; 95% CI, 2.6-7.6; P < .001). Among females (n = 456), FEVAR and OAR showed similar perioperative mortality (8.3% vs 7.0%; P = .73). At 5 years, FEVAR was associated with higher hazards of mortality (43% vs 32%; adjusted HR, 1.5; 95% CI, 1.03-2.2; P = .034) and reintervention (20% vs 3.0%; adjusted HR, 4.8; 95% CI, 2.1-11; P < .001) compared with OAR.
Conclusions:
Among males, FEVAR was associated with favorable perioperative outcomes compared with OAR, although these advantages attenuate over time. However, among females, FEVAR was associated with similar perioperative outcomes, eventually leading to higher reinterventions and possibly higher mortality within 5 years. Future efforts should focus on determining the factors associated with these sex disparities to improve outcomes following FEVAR in females. Based on current evidence, females undergoing elective cAAA repair should be selected with due caution, especially for endovascular repair.
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