Clinical Edge

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Benefits of Endovascular vs Open Repair of AAA

Lancet; 2016 Nov 12; Patel, et al

Publish date:

An early survival benefit was seen with endovascular aneurysm repair (EVAR) compared with open repair, but EVAR also exhibited an inferior late survival, according to a recent study. Data were examined from the EVAR randomized controlled trial which included 1,252 patients (aged ≥60 years) between September 1, 1999, and August 31, 2004. Eligible patients were randomly assigned 1:1 to receive either EVAR (n=626) or open repair (n=626). Researchers found:

  • Over a mean of 12.7 years of follow-up, 9.3 deaths were recorded per 100 person-years in the EVAR group and 8.9 deaths per 100 person-years in the open-repair group (aHR, 1.11).
  • At 0 to 6 months after randomization, patients in the EVAR group had a lower mortality (aHR, 0.61), but beyond 8 years of follow–up, open-repair had a significantly lower mortality (aHR, 1.25).
  • Increased aneurysm-related mortality in the EVAR group after 8 years was mainly attributable to secondary aneurysm sac rupture.

Citation:

Patel R, Sweeting MJ, Powell JT, Greenhalgh RM. Endovascular versus open repair of abdominal aortic aneurysm in 15 years’ follow-up of the UK endovascular aneurysm repair trial 1 (EVAR trail 1): A randomized controlled trial. Lancet. 2016;10058:2366-2374. doi:10.1016/S0140-6736(16)31135-7.

Commentary:

This large trial is consistent with previous trials that have shown that EVAR has an advantage in short-term, that is 30-day, mortality.1,2 Over the long-term though, meaning 2 to 8 years, open repair shows an advantage over EVAR with decreased need for reintervention and decreased mortality. The direct implications of this are 2-fold. First is the importance of this information in advising patients regarding the benefit and risk of EVAR compared to an open procedure, and the second is the need for ongoing surveillance for patients post-EVAR to look for late aneurismal dilatation. Current USPSTF guidelines recommend:

  • One-time screening for abdominal aortic aneurysm (AAA) with ultrasonography in men aged 65 to 75 years who have ever smoked.
  • Selectively offer screening for AAA in men aged 65 to 75 years who have never smoked rather than routinely screening all men in this group.
  • That there is insufficient evidence to assess the balance of benefits and harms of screening for AAA in women aged 65 to 75 years who have ever smoked. —Neil Skolnik, MD
  1. De Bruin JL, Baas AF, Buth J, et al. Long-term outcome of open or endovascular repair of abdominal aortic aneurysm. N Engl J Med. 2010;1881–89.
  2. Lederle FA, Freischlag JA, Kyriakides TC, et al. Long-term comparison of endovascular and open repair of abdominal aortic aneurysm. N Engl J Med. 2012;1988–97.

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