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EVAR Improved Safety vs. Open Repair in Treating AAA
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Among patients with abdominal aortic aneurysms, endovascular aneurysm repair was associated with improved safety compared with open repair, leading researchers to conclude that adoption of the endovascular technique can improve the safety of surgical admissions.
The study, which was published in JAMA Surgery, involved cases of abdominal aortic aneurysm (AAA) repair that were taken from the Nationwide Inpatient Sample from 2003 — when Patient Safety Indicators (PSIs) were established to monitor preventable adverse events during hospitalizations — to 2010. Researchers used Agency for Healthcare Research and Quality software (Win QI, version 4.4) to calculate PSIs.
Year, age, sex, race/ethnicity, comorbidities, rupture status, hospital teaching status and emergency status were the variables included in the unadjusted analysis. In the multivariable analysis, researchers stratified data by year for any PSI in endovascular aneurysm repair (EVAR) or open aneurysm repair. Postoperative mortality served as the control for safety.
Overall, 43,385 EVARs and 27,561 open repairs were featured in the analysis, with those undergoing EVAR being less likely to have any PSI (3% vs. 11.2%; P<.001). EVAR patients were more likely to be male, older and white, seek care at teaching hospitals and have a lower Charlson Comorbidity Index.
Data from the multivariable analysis indicated a more than 40% reduction in the risk-adjusted odds of any PSI in the EVAR group (OR=0.58; 95% CI, 0.51-0.65). Additionally, when stratified by year, the risk-adjusted odds of any PSI were less likely in the EVAR group for every year but 2007, and the likelihood of death was less in every year for those receiving EVAR. Moreover, the annual percentage of PSIs among all aortic repairs decreased from 7.4% in 2003 to 4.4% in 2010, and the rate of repairs that were EVAR increased from 41.1% in 2003 to 75.3% in 2010.
In related data, the rate of mortality was significantly higher after open repair than EVAR (10.6% vs. 1.8%; P<.001; OR=0.28; 95% CI, 0.24-0.32).
“In showing that EVAR is safer than [open aneurysm repair], these results confirm the findings of multiple randomized clinical trials published during the study period and imply a role for PSIs and administrative databases in evaluating the safety of emerging technologies,” the researchers wrote. “In addition, this study adds to the evidence that the adoption of minimally invasive surgical techniques improved the overall safety of AAA repairs nationwide.”
Commenting on the study in an accompanying editorial, Paul N. Suding, MD, and Lamont D. Paxton, MD, private practice clinicians, wrote that the study confirms what vascular surgeons have already put into practice, as endovascular repair has surpassed open repair in the past decade.
“The importance of the article is that it critically appraises a technology, in this case a new approach to aneurysm repair. Furthermore, it gives guidelines for how this analysis can be applied to other surgical innovations,” Suding and Paxton wrote. “The study cannot answer whether endovascular repair is beneficial in the long term because PSIs evaluate patients for only a 30-day period. Moreover, the mortality for open repair … was higher than one would anticipate for this approach and likely indicates that, during the period of the study, open repair remained the preferred technique for emergency operations and for patients who had unfavorable anatomy for endovascular aneurysm repair.
For more information:
Rose J. JAMA Surg. 2014;doi:10.1001/jamasurg.2014.1018.
Suding PN. JAMA Surg. 2014;doi:10.1001/jamasurg.2014.1026.
Disclosure: The researchers, Paxton and Suding report no relevant financial disclosures.
Perspective
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Frank J. Criado, MD, FACS, FSVM
EVAR developments rank high amongst the greatest achievements in vascular surgery. This revolutionary new technique has proven transformative, setting our specialty in an entirely different course as it rapidly evolved to supplant open surgery as the new standard of care for treatment of aortic aneurysms. It has truly changed everything (Criado FJ. J Endovasc Ther. 2010;17:789-796).
The report by Rose and colleagues represents a significant addition to the growing evidence base underpinning current practice where EVAR has become first-line therapy for treatment of AAA in all patients with suitable anatomy — regardless of age or health status. It is indeed reassuring to see how EVAR can be shown to add measurable in-hospital safety for the benefit of patients and society overall. The most impressive difference in operative (30-day) mortality — in favor of EVAR — is likely magnified by the inclusion of emergent and non-EVAR suitable cases in the surgical group. This notwithstanding, the lower mortality is widely viewed as the most significant benefit of EVAR when compared with open repair.
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