Real-World Outcomes of Open Aortic Repair Versus Endovascular Aortic Repair in Ruptured Abdominal Aortic Aneurysms:...

Several studies have demonstrated superior outcomes with endovascular aortic repair (EVAR) compared to open aortic repair (OAR) in patients with infrarenal ruptured abdominal aortic aneurysms (rAAAs). However, in emergent settings, aortic neck suitability for EVAR and adherence to instructions for use criteria are often not met in a significant proportion of patients. We aimed to compare EVAR and OAR in patients with rAAA using a recent national database, incorporating favorable neck (FN) versus hostile neck (HN) anatomy.

We analyzed Vascular Quality Initiative data for rAAA from 2018 to 2024. Two analyses were performed: first, a comparison between OAR and EVAR; second, a comparison among 3 cohorts: OAR, EVAR with FN (EVAR-FN), and EVAR with HN (EVAR-HN). HN anatomy was defined as neck length <15 mm, neck diameter >30 mm, or infrarenal angle >60°. The primary outcomes were 30-day and 1-year mortality. Secondary outcomes included postoperative complications, intensive care unit stay >3 days, red blood cell transfusion >4 units, and postoperative reintervention. Logistic and Cox regressions were used for the analyses.

A total of 4,578 rAAA repairs were performed, of which 3,275 (71.5%) were EVAR. Among EVAR cases, 2,452 (74.9%) had HN anatomy. Thirty-day mortality was 35.5% for OAR and 21.5% for EVAR (P < 0.001). One-year mortality was 43.1% for OAR, 31.5% for all EVARs, 26.4% for EVAR-FN, and 33.2% for EVAR-HN. After adjusting for confounders, EVAR was associated with reduced 30-day and 1-year mortality (adjusted odds ratio [aOR] = 0.66, 95% confidence interval [CI] = 0.52-0.84, P = 0.001; and adjusted hazard ratio [aHR] = 0.79, 95% CI = 0.67-0.93, P = 0.005). EVAR was also associated with reduced risk of postoperative complications. When stratified by neck anatomy, EVAR-FN was associated with more pronounced reduced 30-day (aOR = 0.46, 95% CI = 0.33-0.65; P < 0.001) and 1-year mortality (aHR = 0.66, 95% CI = 0.53-0.82; P < 0.001) compared with OAR. EVAR-HN was associated with reduced 30-day mortality (aOR = 0.74, 95% CI = 0.58-0.94; P = 0.013) but not 1-year mortality (aHR = 0.84, 95% CI = 0.71-1.00; P = 0.052) compared with OAR. EVAR-HN was also associated with increased 30-day and 1-year mortality compared with EVAR-FN.

The majority of rAAAs are treated today with EVAR, and 75% of these patients present with HN anatomy. EVAR was associated with reduced postoperative mortality and complications compared with OAR, regardless of neck anatomy. However, EVAR maintained a 1-year survival advantage over OAR only in patients with FN anatomy. While EVAR-HN demonstrated similar 1-year mortality to OAR, it remains the preferred option due to better perioperative outcomes and lower 30-day mortality. Longer-term follow-up is needed to evaluate reintervention, rupture, and aneurysm-related mortality, particularly in patients with HN anatomy.