ISET: EVAR provides survival but not long-term mortality benefit

Less invasive endovascular aneurysm repair (EVAR) offers an improved survival benefit for patients with ruptured abdominal aortic aneurysms (AAA) compared with surgical repair, according to study results presented Jan. 22 at the International Symposium on Endovascular Therapy (ISET) in Miami Beach, Fla. But long-term mortality remained high in both groups.

Patients with a ruptured AAA have a high probability of dying within the next five years whether the treatment modality is open surgery or endovascular repair, Sherif Sultan, MB, MD, of the Western Vascular Institute at University College Hospital in Galway, Ireland, told Cardiovascular Business. “What we found was a survival benefit in the first three years” with EVAR, he said.

Sultan and colleagues designed a single-center study to compare outcomes between AAA patients who underwent endovascular repair or open repair between 2002 and 2012. Their primary endpoint was aneurysm-related survival, all-cause survival and major adverse cardiovascular events. Secondary endpoints were length of hospital and intensive care unit (ICU) stays and the influence of comorbidities.

Of the 106 confirmed ruptured AAAs, 75 were treated by open surgery and 31 by EVAR. Overall 30-day mortality was higher in the surgery group, at 65 percent vs. 32 percent in the EVAR group. Thirty-day aneurysm-related survival was higher in the EVAR group, at 70 percent vs. 33 percent. There was no statistical difference in all-cause mortality, though. Total aneurysm-related mortality was 12.5 percent in the first week, 25 percent at one month, 37.7 percent at six months, 50 percent at one year and 90 percent at five years.

Although long-term mortality is similar between the treatments, EVAR offers a number of advantages such as improved quality of life and lower costs, Sultan said. Their analysis showed that EVAR procedure time was shorter and blood transfusions were less common in the EVAR group. Post-operative hospital stays were on average almost two days shorter with EVAR, and post-operative ICU stays on average were four days shorter.

Complications appeared to be fewer. None of the EVAR group experienced bowel ischemia (0 percent vs. 11.1 percent of the open repair group), or renal failure (0 percent vs. 22.2 percent). The EVAR group had a lower rate of MI but a higher rate of stroke.

“This service is cost effective with better quality of life for the patient,” Sultan said.

The next step in the research plan is to develop computational models to evaluate thresholds for intervention below the standard diameters of 5.5 cm for men and 4.8 cm for women. Sultan's clinical group already treats AAA patients before they reach those diameters. “At 5.5, the chance of rupture is so huge,” he said. “You are sending the patient to a Russian roulette game.”