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Endovascular Repair of Ruptured Aortic Aneurysms is Not Superior to Open Repair for Patients with Class 3 Obesity
Tarundeep Singh, Sri Ram Pentakota, Joe T. Huang, Frank T. Padberg, Jr, Michael A. Curi, Timothy Wu.
Rutgers University, Newark, NJ, USA.

Objective(s): The purported advantages of endovascular aneurysm repair (EVAR) of ruptured abdominal aortic aneurysms (rAAA) has lead to an exponential increase in its use according to data from the National Surgical Quality Improvement Project (NSQIP). It is unclear, however, if these advantages can be generalized to all populations, including those at the extremes of weight. We report on our analysis of this important patient characteristic and its effect on ruptured aneurysm repair.
Methods: We reviewed the NSQIP database from 2005 through 2015 for all patients with rAAA using appropriate ICD-9 or ICD-10 diagnosis codes and performed a multivariate analysis of patient characteristics undergoing both open aneurysm repair (OAR) and EVAR. Based on calculated BMI (kg/m2) patients were categorized into Underweight (< 18.5), Normal (18.5-<25), Overweight (25-<30), Obese 1 (30-<35), Obese 2 (35-<40), Obese 3 (over 40). Primary outcome measure was 30 day postoperative mortality and secondary outcome measures included total hospital length of stay (LOS) and 30 day composite postoperative complications.
Results: Between 2005 and 2015 52,320 patients were identified with abdominal aortic aneurysm repair in NSQIP and, of these, 4,072 underwent surgical intervention of rAAA. A total of 3,071 patients had a calculated BMI and these were examined. EVAR was performed in 1,293 patients and the remainder underwent OAR (57.9%) with a 30 day postoperative mortality rate of 21.2% and 33.9%, respectively. This 30 day postoperative EVAR mortality advantage over OAR was not noted, however, in patients in both the Underweight (OR 0.59, [95% CI 0.3-1.58]) and Obese 3 (OR 0.53, [95% CI 0.25-1.13]) cohorts. Composite 30 day postoperative complication risk was also similar between EVAR and OAR in the Obese 2 (OR 0.73, [95% CI 0.43-1.24]) and Obese 3 (OR 0.81, [95% CI 0.39-1.68]) cohorts. There was also no difference in LOS between EVAR and OAR in Underweight (5.5 vs. 8 days, p=0.09) and Obese 3 (9 vs. 11 days, p=0.68).
Conclusions: While EVAR has emerged as an acceptable surgical treatment for rAAA, patients at the extremes of weight, particularly those with BMI > 40, should be considered to be at similar risk for postoperative morbidity and mortality between EVAR and OAR. When considering the lifelong surveillance and re-intervention risk of EVAR, its purported advantages over OAR may be overestimated.


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