Open vs endovascular abdominal aortic aneurysm repair in standard surgical-risk patients using a Medicare-matched...

Open surgical repair (OSR) offers the most durable option for abdominal aortic aneurysm repair, yet >80% of repairs in the United States are performed using endovascular aneurysm repair (EVAR). Although EVAR suits high-risk patients, both approaches are viable for standard-risk patients, with the choice often based on operator experience and patient anatomy and preference. This study investigated which technique offers better long-term outcomes in standard-risk patients.

The Medicare-matched Vascular Implant Surveillance and Interventional Outcomes Network database was queried from 2011 to 2019 for standard-risk patients undergoing OSR or EVAR. Patients with high surgical risk features were excluded: age >70 years, body mass index >35, glomerular filtration rate <30, moderate to severe congestive heart failure, recent myocardial infarction, positive stress test, home oxygen, dialysis dependent, and patients unfit for OSR based on surgeon judgment. Patients presenting with rupture or with prior aneurysm repair were also excluded. Propensity score matching was used to match baseline characteristics (26 variables) in both groups. Cox regression analyzed mortality, aneurysm-related reintervention, and rupture up to 7 years.

Before matching, our study included 7409 standard-risk patients (EVAR, 5933 [80.1%]; OSR, 1476 [19.9%]). Propensity score matching produced two well-balanced cohorts of 1017 pairs. There was no significant difference in 7-year mortality (HR, 1.08; 95% confidence interval [CI], 0.85-1.38; P = .511). However, EVAR was associated with a higher risk of reintervention at 7 years compared with OSR (20.8% vs 12.4%; HR, 1.56; 95% CI, 1.17-2.07; P = .002). Furthermore, the hazard of rupture was almost four-fold higher with EVAR (3.2% vs 0.4%; HR, 3.87; P = .018).

In the current era, where EVAR is the predominant choice even in low surgical risk patients, reasons to undergo OSR are limited. However, our study demonstrates superior durability of OSR in standard-risk patients with significantly lower rates of reintervention and rupture up to 7 years. Our findings provide a strong rationale for performing OSR in physiologically fit patients.