Prior studies have established endovascular repair as preferred over open repair when it comes to short-term outcomes in AAA, but concerns remained about the durability of this method -- and whether the finding held true for a less selective study population. Therefore, researchers at Beth Israel Deaconess Medical Center and Harvard Medical School sought to draw some conclusions from long-term, population-based data. They looked at Medicare beneficiaries 67 years of age or older for whom at least 2 years of prior claims data were available. Patients who had elective AAA repair (no rupture had occurred) between 2001 and 2004 and who had a procedural code for either open surgical repair or endovascular repair were included. Participants also had to be covered by both Medicare Parts A and B.

After matching, there were 44,660 patients, with 22,830 in each cohort. Approximately 20 percent were women and the average age was 76 years. Endovascular repair patients were older and more likely to have coexisting conditions than those who underwent open repair. Study authors found that all major medical complications such as myocardial infarction, pneumonia, and acute renal failure were more likely after open repair, and the mean length of hospital stay for open repair was 9.3 days as opposed to 3.4 days after endovascular repair.

As for long-term outcomes, the rate of rupture by year 4 was 3 times greater in the endovascular-repair group, as were reinterventions related directly to AAA. However, rupture was uncommon in both cohorts (1.8 percent for endovascular repair, 0.5 percent for open repair) and the majority of reinterventions were minor. The rate of laparotomy-related complications was higher for patients who had open repair. The authors suggest that these 2 risks may offset each other, and that the overall survival benefit of endovascular repair is more durable than previously thought. As they mention, there is potential bias inherent in the observational nature of their study. Clinical trials that further explore this topic in the Medicare population are thus needed.

Michael R. Jaff, DO, Medical Director, Massachusetts General Hospital Vascular Center, states: "Evolution to 'less invasive' therapy for cardiovascular disease has been ongoing for the past decade or so. However, many changes in treatment away from open surgery have occurred without the highest level of scientific evidence. For repair of abdominal aortic aneurysms, it is intuitively obvious that endovascular stent grafts are desirable when compared to open surgery. Comparative studies have demonstrated the short-term advantages of this strategy. However, these data are very compelling, and provide important reassurance that endovascular repair of abdominal aortic aneurysms results in reduction in short- and long-term complications as well as mortality. We continue to learn that the need for repeat intervention, although a less major procedure than initial aneurysm repair, is more likely after endograft repair. These data are helpful in planning strategies for aneurysm repair: If the patient is an anatomic candidate for endograft repair, and understands the need for regular surveillance, this may be the optimal first-line treatment."

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Source:Schermerhorn ML, O'Malley AJ, Jhaveri A, et al. 2008. Endovascular vs. open repair of abdominal aortic aneurysms in the Medicare population. Published January 31, 2008 on the New England Journal of Medicine website.

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