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Comparable Perioperative Outcomes in Younger Patients Undergoing Elective Open and Endovascular Abdominal Aortic Aneurysm Repair
Nathan L. Liang, MD, MS1, Katherine M. Reitz, MD1, Michel S. Makaroun, MD1, Mahmoud Malas, MD2, Edith Tzeng, MD1.
1University of Pittsburgh Medical Center, Pittsburgh, PA, USA, 2Johns Hopkins Medical Institutes, Baltimore, MD, USA.

Objective(s):
Evidence for benefit of endovascular (EVAR) over open surgical repair for de novo infrarenal abdominal aortic aneurysms (AAA) in younger patients remains conflicting due to heterogeneous study populations and small sample sizes. The objective of this study is to compare short and mid-term outcomes for EVAR and open surgery in younger patients using a large national disease and procedure specific dataset.
Methods:
We identified patients 65 years of age and under receiving first-time elective EVAR or open AAA repair from the Vascular Quality Initiative (2003-2014). We excluded those with pararenal or thoracoabdominal aneurysms, patients medically unfit for open repair, and EVAR for isolated iliac aneurysms. Clinical and procedural characteristics were balanced using inverse propensity of treatment weighting. A supplemental analysis extended the study to those under 70 years old.
Results:
We identified 2641 patients; 73% (n=1928) EVAR and 27% (n=713) open. The median age was 62 (IQR 59-64) and 13% were female. The median follow-up time was 401d (IQR 357-459). Unadjusted 30-day survival was 99.6% overall (open: 99.1%; EVAR: 99.8%; P<0.001) with 97.4% 1-year survival overall (open: 97.3%; EVAR: 97.4%; P=0.9). Unadjusted reintervention rates were 5 (open) and 7 (EVAR) reinterventions per 100 person-years (P=0.8). After propensity weighting, the absolute incidence of perioperative mortality was less than one percent in both groups (Figure) and complication rates were low. Propensity-weighted survival (HR 0.88, 95% CI [0.56-1.38]; P=0.6) and reintervention rates (open: 6; EVAR: 8; reinterventions per 100 person-years; P=0.8) did not differ between the two interventions. The under-70 analysis showed similar results.
Conclusions:
In this study of younger patients undergoing repair of infrarenal AAA, 30-day morbidity and mortality for both open surgery and EVAR are extremely low and the absolute mortality difference is small. The prior published perioperative mortality benefit of EVAR over open AAA repair is not observed in younger patients. Further studies of long-term durability are needed to guide decision making for open versus EVAR in this population.


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