- Email: [email protected]
Durability and survival are similar after elective endovascular and open repair of abdominal aortic aneurysms in younger patients
From the Eastern Vascular Society
Durability and survival are similar after elective endovascular and open repair of abdominal aortic aneurysms in younger patients Kevin Lee, MD, Elaine Tang, Luc Dubois, MD, MSc, Adam H. Power, MPhil (Cantab), Guy DeRose, MD, and Thomas L. Forbes, MD, London, Ontario, Canada Objective: The role of endovascular repair (EVAR) of aortic aneurysms in young patients is controversial. The purpose of this study was to determine the long-term outcomes and reintervention rates in patients 60 years of age or younger who underwent elective open or endovascular repair of an abdominal aortic aneurysm. Methods: Retrospective review of a prospectively collected vascular surgery database at a university-affiliated medical center was performed to identify all patients who underwent elective repair of an abdominal aortic aneurysm between 2000 and 2013 and were 60 years of age or younger at the time of the repair. Preoperative anatomic measurements were performed and compared with instructions for use (IFU) criteria for the endografts. Results: The study cohort comprised 169 patients 60 years of age or younger (mean age, 56.7 6 2.8 years) who underwent elective repair (119 open repair, 50 EVAR). Patients treated with open repair and EVAR had similar comorbidities, except that EVAR patients were more likely to have hypertension (P [ .03) and poor left ventricular function (P [ .04). The open repair group had significantly larger suprarenal (P [ .004) and infrarenal (P [ .005) neck angles, shorter neck lengths (P < .001), and larger maximum aneurysm diameter (P [ .02) compared with the EVAR group. Only five patients (13%) in the EVAR group did not meet all IFU criteria. The overall in-hospital mortality rate was 1.8% (0% EVAR, 2.5% open repair; P [ .56). Overall mean life expectancy was 11.5 years (9.8 years EVAR, 11.9 years open repair; P [ .09). The 1-year (98% EVAR, 96% open repair), 5-year (86% EVAR, 88% open repair), and 10-year (54% EVAR, 75% open repair) survival did not differ between EVAR and open repair (P [ .16). Long-term survival (78% EVAR, 85% open repair; P [ .09) and reintervention rates (12% EVAR, 16% open repair; P [ .80) did not differ. No late aneurysm rupture or aneurysm-related deaths were observed. The most common causes of long-term mortality were malignant disease and cardiovascular events. Reinterventions in the open repair group were exclusively laparotomy related (incisional hernia repairs), whereas all reinterventions in the EVAR group were aortic related, including one conversion to open repair. Conclusions: After elective aneurysm repair, younger patients have a moderate life expectancy related to malignant disease and cardiovascular health. EVAR offers durability and long-term survival similar to those with open repair in these younger patients as long as aneurysm anatomy and IFU are adhered to. (J Vasc Surg 2015;61:636-41.)
Since its first report in 1991,1 endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms (AAAs) has become an established and preferred method of treatment in many patients. Several randomized controlled trials comparing EVAR and open repair have revealed an early survival advantage, a lower perioperative morbidity rate, and a shorter hospital stay with EVAR.2-4 As a result,
From the Division of Vascular Surgery, London Health Sciences Centre and The University of Western Ontario. Author conflict of interest: none. Presented at the Twenty-eighth Annual Meeting of the Eastern Vascular Society, Boston, Mass, September 11-14, 2014. Reprint requests: Thomas L. Forbes, MD, University Health Networke Toronto General Hospital, 200 Elizabeth St, Eaton North 6-222, Toronto, ON, Canada, M5G 2C4 (e-mail: [email protected]). The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. 0741-5214 Copyright Ó 2015 by the Society for Vascular Surgery. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jvs.2014.10.012
636
EVAR has become the most frequent method of elective repair of AAAs at most vascular centers, including ours.5 However, some believe that EVAR is not the preferred approach in younger patients with long life expectancies because of concerns about durability, reinterventions, surveillance requirements, and lack of an early survival advantage. A study using information from the National Surgical Quality Improvement Program revealed similar in-hospital mortality rates between open repair (0.4%) and EVAR (1.1%) in patients younger than 60 years.6 Reintervention rates are also a concern in younger patients, although some randomized trial information suggests similar reintervention rates between EVAR and open repairs when laparotomyrelated reinterventions are included in the open group.7 Two reports8,9 from England suggest that young patients with aneurysms do not have the life expectancy of nonaneurysm patients, which is pertinent in considering the durability of any repair and surveillance requirements. These studies, however, did not investigate the role of aneurysm anatomy or adherence to the devices’ instructions for use (IFU) criteria, which are known to be key determinants of EVAR durability and risk of reintervention.10
JOURNAL OF VASCULAR SURGERY Volume 61, Number 3
The purpose of this study was to review our center’s early and late outcomes with elective repair of AAAs in young patients (60 years of age or younger at the time of repair) and to analyze aneurysm anatomy and its possible role in EVAR durability. METHODS A retrospective review of a prospectively collected database at our university-affiliated medical center was performed to identify all patients who were 60 years of age or younger at the time of their elective endovascular or open repair of an AAA between 2000 and 2013. Missing information was obtained through chart review. Long-term mortality and information about reinterventions were confirmed by contacting individual patients or family members. All reinterventions related to the initial AAA repair were reviewed, including all aortic and access-related procedures, laparotomies for bowel obstructions and incisional hernia repairs, and femoral-femoral crossover complications (infection, thrombosis). Superficial wound infections were not included and are not the focus of this study. Exclusion criteria included ruptured or symptomatic aneurysms, fenestrated endografts, prior infrarenal aortic surgery, aneurysm requiring suprarenal clamping or renal or mesenteric artery procedures, connective tissue disorders, mycotic aneurysms, and aneurysms associated with aortic dissections. Preoperative anatomic measurements were performed by centerline measurements and commercially available three-dimensional reconstruction software (TeraRecon, San Mateo, Calif). A composite list of IFU criteria was defined as suprarenal aortic angulation <60 degrees, infrarenal aortic neck angulation <75 degrees, aneurysm infrarenal neck length >15 mm and diameter between 18 and 32 mm, and common iliac artery distal fixation length >10 mm and diameter between 8 and 25 mm. These patients received endovascular or open repair in a nonrandomized fashion at the discretion of their attending surgeon after consideration of such issues as aneurysm anatomy, patient comorbidities, and patient preference. Open repair was performed with a midline incision and transperitoneal approach with an infrarenal clamp and a straight or bifurcated graft, depending on the extent of the aneurysm, and any coexisting aortoiliac occlusive disease with a woven tube or bifurcated graft. EVAR was performed with one of the following stent grafts by bilateral groin cutdowns: Talent (Medtronic, Minneapolis, Minn), Endurant (Medtronic), or Zenith (Cook Medical, Bloomington, Ind). After EVAR procedures, postoperative surveillance consisted primarily of computed tomography (CT) scans during the earlier years of the study but more recently transitioned to annual ultrasound examinations following evidence of aneurysm sac regression and absence of endoleak on the 1-year CT scan. It was recommended that patients receive a CT scan 5 years after open repair by their primary care physicians. These CT scans were not reviewed for this study. Statistical analysis was performed with SPSS Statistics version 20.0 (IBM, Armonk, NY). Comparison of categorical
Lee et al 637
Table I. Patient demographic and endovascular aneurysm repair (EVAR) details
Mean age, years % Male Coronary artery disease Previous PCI Previous CABG Left ventricular dysfunction Arrhythmia HTN DM Smoking Current Previous smoker COPD CHOL Dialysis CKD Configuration for EVAR Bifurcated Aortouni-iliac Stent graft type Medtronic Talent Medtronic Endurant Cook Zenith
EVAR (n ¼ 50), No. (%)
Open (n ¼ 119), No. (%)
57.1 92 15 (30) 6 9 8 (16) 5 (10) 43 (86) 14 (28)
56.6 92 29 (24) 8 21 7 (6) 6 (5) 82 (69) 27 (23)
.2 1.00 .50
23 18 12 36 1 4
51 56 17 70
.77 .16 .32 .14 .30 1.000
(46) (36) (24) (72) (2) (8)
(43) (47) (21) (59) 0 10 (8)
P value
.04 .31 .03 .50
36 (72) 14 (28) 13 (26) 13 (26) 24 (48)
CABG, Coronary artery bypass graft; CHOL, cholesterol; CKD, chronic kidney disease; COPD, chronic obstructive pulmonary disease; DM, diabetes mellitus; HTN, hypertension; PCI, percutaneous coronary intervention. Coronary artery disease is defined as previous documented myocardial infarction treated medically, percutaneous coronary intervention, or coronary artery bypass graft. Left ventricular dysfunction is defined as ejection fraction <55%. Chronic obstructive pulmonary disease is defined as forced expiratory volume in 1 second (FEV1) <80% and FEV1/forced vital capacity <0.70. Chronic kidney disease is defined as estimated glomerular filtration rate <60 mL/min/1.73 m2.
variables was done by the c2 test and Fisher exact test, whereas continuous variables were analyzed by nonpaired t-tests. Long-term survival and freedom from reintervention were determined by life-table analysis and Kaplan-Meier curves and log-rank tests. Results are reported as mean 6 standard deviation, and the level of statistical significance was set at P < .05. Individual patient consent for study inclusion was not obtained or required, and this study received approval from the University of Western Ontario Research Ethics Board for Health Sciences Research Involving Human Subjects. RESULTS Initially, 203 consecutive patients aged 60 years or younger who underwent AAA repair between January 2000 and December 2013 were identified. The final study cohort included 169 patients after 34 patients were excluded (two with connective tissue disorders, three with mycotic aneurysms, two with aortic dissections, and 27 with ruptured aneurysms). Of these 169 patients, 50 (30%) underwent EVAR and 119 (70%) received open repair. Mean age was 56.7 6 2.8 years and 92% of patients were male, with no difference between groups. The two treatment groups were similar with respect to the incidence
JOURNAL OF VASCULAR SURGERY March 2015
638 Lee et al
Table II. Preoperative anatomic data for endovascular aneurysm repair (EVAR) and open repair groups
Suprarenal angulation Infrarenal angulation Neck length Neck diameter AAA maximum diameter Right CIA length Right CIA diameter Left CIA length Left CIA diameter Outside of IFU criteria Aneurysm angulation Neck anatomy Iliac artery anatomy
EVAR (n ¼ 39)
Open (n ¼ 38)
4.2 16.9 30.6 22.6 56.4 48.7 15.1 48.9 14.5 5 0 4 1
13.0 28.7 19.9 21.7 63.7 51.5 19.0 51.2 17.0 16 2 9 5
Table III. Early in-hospital results
P value .004 .005 <.001 .22 .02 .51 .07 .56 .16 .004
AAA, Abdominal aortic aneurysm; CIA, common iliac artery; IFU, instructions for use.
of preoperative coronary artery disease, arrhythmia, diabetes, smoking, pulmonary disease, and renal insufficiency (Table I). However, patients receiving endovascular repair were more likely to suffer from hypertension (EVAR, 86%; open repair, 69%; P ¼ .03) and poor left ventricular function (EVAR, 16%; open repair, 6%; P ¼ .04). In the EVAR group, 36 patients received bifurcated devices and 14 were treated with aortouni-iliac endografts. The majority of the aortouni-iliac grafts were placed early during this experience by one of our surgeons and seldom after 2005. Endografts used included 13 Medtronic Talent (26%), 13 Medtronic Endurant (26%), and 24 Cook Zenith (48%). Preoperative anatomic data were collected from 39 patients from the EVAR group and 38 patients from the open repair group as summarized in Table II. Unfortunately, the remaining preoperative CT scans were unavailable for review. Preoperative anatomic information was more commonly available once it was included in our database after 2005. The open repair group had significantly larger suprarenal (open repair, 13.0 degrees; EVAR, 4.2 degrees; P ¼ .004) and infrarenal (open repair, 28.7 degrees; EVAR, 16.9 degrees; P ¼ .005) neck angles. The mean infrarenal neck length was shorter in the open repair group (open repair, 19.9 mm; EVAR, 30.6 mm; P < .001), and maximum aneurysm diameter was larger in the open repair group (open repair, 63.7 mm; EVAR, 56.4 mm; P ¼ .02). There was no significant difference between the groups regarding infrarenal neck diameter and common iliac artery length or diameter. Only five patients did not meet all IFU criteria in the EVAR group (13%) compared with 16 in the open repair group (42%; P ¼ .004). Of the five patients in the EVAR group, one patient had a right common iliac artery diameter of 26 mm, one patient had a neck diameter of 14 mm, and three patients had neck lengths <15 mm. One of the five non-IFU EVAR patients required open conversion for chronic thrombosis of an aortouni-iliac stent graft.
EVAR (n ¼ 50), No. (%)
Open (n ¼ 119), No. (%)
0 (0) 1 (2) 1 0 3.2
3 (2.5) 3 (2.5) 0 3 7.9
In-hospital mortality rate In-hospital reintervention rate Endovascular reintervention Surgical reintervention Length of hospital stay, days
P value .56 .66 <.001
EVAR, Endovascular aneurysm repair.
Table IV. Long-term survival and reintervention rates
Survival rate, % (No.) Cause of mortality AAA-related death Non-AAA-related death Unknown Lost to follow-up Mean follow-up length, months Reintervention rate, % (No.) Endovascular Surgical
EVAR (n ¼ 50)
Open (n ¼ 116)
78 (39)
85 (86)
0 7 4 0 62.5 12 (6) 2 4
0 13 2 15 78.2 16 (16) 0 16
AAA, Abdominal aortic aneurysm; EVAR, endovascular aneurysm repair.
There were three in-hospital deaths (2.5%) in the open repair group and none in the EVAR group (P ¼ .6). The overall in-hospital mortality rate was 1.8% (Table III). The deaths in the open repair group were due to respiratory failure in two cases and cardiac arrest in the other. Length of stay was significantly shorter after EVAR (EVAR, 3.2 days; open repair, 7.9 days; P < .001). One patient (2%) in the EVAR group required early reintervention during the index admission (renal artery stent for partial coverage of a renal artery). Three patients (2.5%) required early reintervention during the index admission in the open group (lower extremity embolectomy in two cases and repair of a wound dehiscence in the other). These early reintervention rates did not differ between the two groups (P ¼ .66). Mean length of follow-up for the EVAR and open repair groups were 62.5 months (median, 57.7 months) and 78.2 months (median, 86.8 months), respectively. Overall mean life expectancy was 11.5 years, and there was no difference between the two groups (EVAR, 9.8 years vs open repair, 11.9 years; P ¼ .09). There was also no difference in long-term survival rate between the two groups (EVAR, 78% vs open repair, 85%; P ¼ .09; Table IV). Kaplan-Meier survival analysis showed that the survival rate at 1 year (EVAR 98% vs open repair 96%), 5 years (EVAR, 86% vs open repair, 88%), and 10 years (EVAR, 54% vs open repair, 75%) did not differ between EVAR and open groups (P ¼ .16; Fig 1). Most common causes of long-term mortality were malignant disease and cardiovascular-related deaths (Table V). There were no
JOURNAL OF VASCULAR SURGERY Volume 61, Number 3
Fig 1. Kaplan-Meier survival curve for endovascular aneurysm repair (EVAR) group vs open repair group (log-rank, P ¼ .09). Standard error <10% for all intervals for open group; in EVAR, only 96 and 120 months over >10% at 11% and 12%.
aneurysm ruptures or late aneurysm-related deaths in either repair group. The long-term reintervention rate was not significantly different between the two groups (EVAR 12% vs open repair 16%; P ¼ .80; Fig 2). The majority of reinterventions in the open group were incisional hernia repairs. In contrast, all reinterventions in the EVAR group were related to the initial aneurysm repair (Table V). Two patients suffered from thrombosis of an endograft limb (one patient with aortouni-iliac and one with bifurcated endograft), resulting in an axillary-femoral bypass and femoral-femoral crossover graft. There were no instances of crossover graft thrombosis, although one crossover graft had to be removed because of infection. During surveillance, 16% of patients were observed to have a type II endoleak at some point. However, there were no instances of sac expansion, so none of these endoleaks were intervened on or resulted in adverse sequelae. The only reintervention for an endoleak was for a type Ib endoleak, repaired with an iliac extension. One patient required conversion to open repair because of complete thrombosis of a bifurcated endograft 2 months after the initial procedure. There were no mortalities related to these reinterventions. DISCUSSION This retrospective single-center study demonstrates that patients 60 years of age or younger do equally well after elective endovascular or open repair of their AAA with similar chances of survival during the perioperative period (no early deaths in the EVAR group) and at 1, 5, and 10 years after their initial repair, despite higher rates of hypertension and left ventricular dysfunction in patients undergoing EVAR. Causes of death were predominantly due to malignant diseases and non-aneurysm-related cardiovascular events. Chances of additional procedures did
Lee et al 639
not depend on method of repair when all aortic and nonaortic reinterventions were considered. A major caveat of these findings is that the large majority of EVAR patients fit the IFU of available endografts, which is known to be an important predictor of EVAR durability.10 By following the IFU, our EVAR group comprised patients with aortic anatomy that should predict excellent short- and longterm results. There have been some concerns regarding EVAR in younger patients, including a questionable early survival benefit and durability concerns in these supposedly goodrisk patients with long life expectancies. We failed to show a perioperative survival advantage with EVAR, with an overall in-hospital mortality rate of 1.8% in these patients 60 years of age or younger (no in-hospital deaths after EVAR). However, our EVAR patients were somewhat disadvantaged with more frequent instances of hypertension and compromised left ventricular function and might represent a higher risk group than our open repair patients. These findings are similar to those of the randomized Anevrysme de l’aorte abdominale: Chirurgie vs Endoprothese (ACE) trial11 of low-risk patients and two recent and similar reports from England examining patients 65 years of age or younger that also reported very low in-hospital mortality rates (0.6% and 3.7%) that did not differ between methods of repair.8,9 There is increased evidence that young AAA patients do not have the same life expectancy as patients without aneurysms. In a recent follow-up report from the Dutch Randomized Endovascular Aneurysm Management (DREAM) trial, one third of patients had died 6 years after their repair, with age older than 70 years, cardiovascular disease, and smoking being predictive of poor survival and statin use being protective.12 When analysis was limited to patients 65 years of age or younger, the group from Nottingham observed that 40% of patients died after a median followup of 77 months (6.5 years).8 After review of the English National Health Service data set, the St. George’s group reported that AAA patients were disadvantaged, with a 5year survival rate of 67.4% compared with 81.1% for controls.13 These experiences and others suggest that AAAs reflect a degree of increased cardiovascular risk with respect to life expectancy and that durability of EVAR in younger patients may not be of any more concern than with older patients. However, our study cohort exhibited better 5-year survival rates (86% and 88%) than in these reports, which suggests that longer life expectancy and procedure durability are issues in these younger patients. We are unsure of the reasons for this improved survival in our patients, whether it is related to such unstudied factors as statin use, as was found in the DREAM trial,12 or because our study examined younger patients (60 years of age and younger) compared with the other studies.8,9 Although it is not statistically significant, there was a trend toward improved 10-year survival after open repair compared with EVAR (75% vs 54%). This may reflect the increased cardiovascular risk burden exhibited by our EVAR cohort.
JOURNAL OF VASCULAR SURGERY March 2015
640 Lee et al
Table V. Causes of long-term mortality and reinterventions EVAR Cause of death
3 1 3 4
Reintervention details
1 1 1 1
Open
Cancer Gastrointestinal Cardiac Unknown
Axillary-femoral artery bypass for thrombosed stent graft Excision of femoral-femoral crossover graft for infection Open conversion from thrombosed stent graft Femoral-femoral crossover graft for stent graft limb thrombosis 1 External iliac artery angioplasty and stent 1 Repair of type Ib endoleak
1 Perforated bowel 8 Cancer 3 Cardiac 1 Trauma 2 Unknown 13 Incisional hernia repairs 1 Femoral-femoral crossover graft for limb thrombosis 1 Thrombectomy of graft and distal bypass 1 Ilioprofunda bypass
EVAR, Endovascular aneurysm repair.
Fig 2. Freedom from reintervention for elective endovascular aneurysm repair (EVAR) group vs elective open repair group (logrank, P ¼ .80). Standard error <10% for all intervals.
With potentially longer life expectancies, there has also been concern about higher reintervention rates in younger patients after EVAR compared with open repair. This has been especially evident when only aortic or aneurysm-related reinterventions are included. However, when we examined all reinterventions, including laparotomy-related procedures for bowel obstructions or incisional hernias, there was no difference in risk of reintervention between repair methods (EVAR, 12%; open repair, 16%). This is consistent with the Nottingham experience that studied patients 65 years of age or younger.8 In contrast, the Leicester group, with a similar study cohort, observed more frequent reinterventions after EVAR.9 However, half of the reinterventions in the EVAR group were secondary to type I endoleaks. They did not report anatomic measurements, but their finding could reflect anatomic selection factors, such as infrarenal neck anatomy, that are predictive of attachment site failures.10,14 By adhering to endograft IFU, our study reveals that these attachment site endoleaks can be generally
prevented, a finding that has been observed in larger studies.10,14-16 The majority of reinterventions in our EVAR cohort were related to ischemic or thrombotic complications rather than to endoleaks, raising the possibility that EVAR could offer a lower reintervention rate if these issues were reduced with better patient selection or adjunct techniques. This study differs from two similar recent reports from England8,9 in that preoperative anatomic information is included. It has been previously demonstrated that more than half of patients in the United States who undergo EVAR have anatomy outside the endograft’s IFU10 and exhibit higher rates of graft thrombosis, reintervention, and sac enlargement.17 Because IFU are specific to different devices, we used a composite set that included infrarenal aneurysm neck length of 15 mm or longer as shorter necks are associated with an increased risk of type I endoleaks in the short and midterms.15 Some newer generation endografts, such as some used in this study, have shorter neck lengths as part of their IFU. Regardless, these results validate our approach to offer EVAR to young patients only if their anatomy adheres to the IFU for a durable repair over the longer term. Those young patients with aneurysm anatomy outside the IFU are better served with open repair to avoid aortic-specific reinterventions. These include the larger aneurysms that were generally treated with open repair at our center and are less inclined to have anatomy that adheres to the IFU. Larger aneurysms (>6 cm) are known to have a higher risk of rupture, conversion to open repair, and aneurysm-related mortality after EVAR.18,19 Our study has the limitations inherent in a nonrandomized, single-center, retrospective analysis of a moderate number of patients. No patients were lost to follow-up in the EVAR group, but 15 patients were lost to follow-up in the open repair group. During long-term follow-up, there were six patients in whom the cause of death was undetermined; four were in the EVAR group and two in the open repair group. None of these patients in the EVAR group had endoleaks, graft migration, or kinking in the most recent CT scans performed before their death. Last,
JOURNAL OF VASCULAR SURGERY Volume 61, Number 3
anatomic data were available in only 78% of the EVAR patients because the other 22% had their preoperative CT scans at a different institution or their CT scans were not available. The limited preoperative anatomic information for both repair groups is a limitation. In addition, given the nonrandomized comparison between groups, differences in unaccounted for confounders (other comorbidities, functional status, statin use) between the two groups may have influenced the results. CONCLUSIONS Open repair or EVAR in the treatment of young patients with AAAs has been a topic of debate because of the concern of durability and reintervention risk after endovascular repair. This study shows that younger patients who undergo elective EVAR have survival, durability, and reintervention rates similar to those of open repair patients (despite higher rates of some cardiac comorbidities), as long as aneurysm anatomy is considered and endograft IFU are strictly adhered to. These young aneurysm patients have a moderate life expectancy related primarily to malignant disease and cardiovascular events but similar chances of long-term survival regardless of the method of initial repair. Especially in higher risk younger patients, EVAR should be the method of repair in anatomically suitable patients, with similar outcomes expected at 5 and 10 years compared with open repair. AUTHOR CONTRIBUTIONS Conception and design: KL, TF Analysis and interpretation: KL, LD, AP, GD, TF Data collection: KL, ET Writing the article: KL, TF Critical revision of the article: KL, ET, LD, AP, GD, TF Final approval of the article: KL, ET, LD, AP, GD, TF Statistical analysis: KL, ET Obtained funding: Not applicable Overall responsibility: TF REFERENCES 1. Parodi JC, Palmaz JC, Barone HD. Transfemoral intraluminal graft implantation for abdominal aortic aneurysms. Ann Vasc Surg 1991;5: 491-9. 2. Greenhalgh RM, Brown LC, Kwong GP, Powell JT, Thompson SG; EVAR trial participants. Comparison of endovascular aneurysm repair with open repair in patients with abdominal aortic aneurysm (EVAR trial 1), 30-day operative mortality results: randomised controlled trial. Lancet 2004;364:843-8. 3. Lederle FA, Freischlag JA, Kyriakides TC, Padberg FT Jr, Matsumura JS, Kohler TR, et al. Outcomes following endovascular vs open repair of abdominal aortic aneurysm: a randomized trial. JAMA 2009;302:1535-42.
Lee et al 641
4. Prinssen M, Verhoeven EL, Buth J, Cuypers PW, van Sambeek MR, Balm R, et al. A randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms. N Engl J Med 2004;351:1607-18. 5. Chadi SA, Rowe BW, Vogt KN, Novick TV, Harris JR, Derose G, et al. Trends in management of abdominal aortic aneurysms. J Vasc Surg 2012;55:924-8. 6. Gupta PK, Ramanan B, Lynch TG, Gupta H, Fang X, Balters M, et al. Endovascular repair of abdominal aortic aneurysm does not improve early survival versus open repair in patients younger than 60 years. Eur J Vasc Endovasc Surg 2012;43:506-12. 7. Lederle FA, Freischlag JA, Kyriakides TC, Matsumura JS, Padberg FT Jr, Kohler TR, et al. Long-term comparison of endovascular and open repair of abdominal aortic aneurysm. N Engl J Med 2012;367:1988-97. 8. Altaf N, Abisi S, Yong Y, Saunders JH, Braithwaite BD, MacSweeney ST. Mid-term results of endovascular aortic aneurysm repair in the young. Eur J Vasc Endovasc Surg 2013;46:315-9. 9. Sandford RM, Choke E, Bown MJ, Sayers RD. What is the best option for elective repair of an abdominal aortic aneurysm in a young fit patient? Eur J Vasc Endovasc Surg 2014;47:13-8. 10. Schanzer A, Greenberg RK, Hevelone N, Robinson WP, Eslami MH, Goldberg RJ, et al. Predictors of abdominal aortic aneurysm sac enlargement after endovascular repair. Circulation 2011;123:2848-55. 11. Becquemin JP, Pillet JC, Lescalie F, Sapoval M, Goueffic Y, Lermusiaux P, et al. A randomized controlled trial of endovascular aneurysm repair versus open surgery for abdominal aortic aneurysms in low- to moderate-risk patients. J Vasc Surg 2011;53:1167-73.e1. 12. de Bruin JL, Baas AF, Heymans MW, Buimer MG, Prinssen M, Grobbee DE, et al. Statin therapy is associated with improved survival after endovascular and open aneurysm repair. J Vasc Surg 2014;59:39-44.e1. 13. Karthikesalingam A, Bahia SS, Patterson BO, Peach G, Vidal-Diez A, Ray KK, et al. The shortfall in long-term survival of patients with repaired thoracic or abdominal aortic aneurysms: retrospective casecontrol analysis of hospital episode statistics. Eur J Vasc Endovasc Surg 2013;46:533-41. 14. Hobo R, Sybrandy JE, Harris PL, Buth J; EUROSTAR Collaborators. Endovascular repair of abdominal aortic aneurysms with concomitant common iliac artery aneurysm: outcome analysis of the EUROSTAR Experience. J Endovasc Ther 2008;15:12-22. 15. Leurs LJ, Kievit J, Dagnelie PC, Nelemans PJ, Buth J; EUROSTAR Collaborators. Influence of infrarenal neck length on outcome of endovascular abdominal aortic aneurysm repair. J Endovasc Ther 2006;13:640-8. 16. Vallabhaneni R, Farber MA, Schneider F, Ricco JB. Debate: whether young, good-risk patients should be treated with endovascular abdominal aortic aneurysm repair. J Vasc Surg 2013;58:1709-15. 17. Abbruzzese TA, Kwolek CJ, Brewster DC, Chung TK, Kang J, Conrad MF, et al. Outcomes following endovascular abdominal aortic aneurysm repair (EVAR): an anatomic and device-specific analysis. J Vasc Surg 2008;48:19-28. 18. Peppelenbosch N, Buth J, Harris PL, van Marrewijk C, Fransen G; EUROSTAR Collaborators. Diameter of abdominal aortic aneurysm and outcome of endovascular aneurysm repair: does size matter? A report from EUROSTAR. J Vasc Surg 2004;39:288-97. 19. Zarins CK, Crabtree T, Bloch DA, Arko FR, Ouriel K, White RA. Endovascular aneurysm repair at 5 years: does aneurysm diameter predict outcome? J Vasc Surg 2006;44:920-9; discussion: 929-31.
Submitted Jul 30, 2014; accepted Oct 8, 2014.
Durability and survival are similar after elective endovascular and open repair of abdominal aortic aneurysms in younger patients Kevin Lee, MD, Elaine Tang, Luc Dubois, MD, MSc, Adam H. Power, MPhil (Cantab), Guy DeRose, MD, and Thomas L. Forbes, MD, London, Ontario, Canada Objective: The role of endovascular repair (EVAR) of aortic aneurysms in young patients is controversial. The purpose of this study was to determine the long-term outcomes and reintervention rates in patients 60 years of age or younger who underwent elective open or endovascular repair of an abdominal aortic aneurysm. Methods: Retrospective review of a prospectively collected vascular surgery database at a university-affiliated medical center was performed to identify all patients who underwent elective repair of an abdominal aortic aneurysm between 2000 and 2013 and were 60 years of age or younger at the time of the repair. Preoperative anatomic measurements were performed and compared with instructions for use (IFU) criteria for the endografts. Results: The study cohort comprised 169 patients 60 years of age or younger (mean age, 56.7 6 2.8 years) who underwent elective repair (119 open repair, 50 EVAR). Patients treated with open repair and EVAR had similar comorbidities, except that EVAR patients were more likely to have hypertension (P [ .03) and poor left ventricular function (P [ .04). The open repair group had significantly larger suprarenal (P [ .004) and infrarenal (P [ .005) neck angles, shorter neck lengths (P < .001), and larger maximum aneurysm diameter (P [ .02) compared with the EVAR group. Only five patients (13%) in the EVAR group did not meet all IFU criteria. The overall in-hospital mortality rate was 1.8% (0% EVAR, 2.5% open repair; P [ .56). Overall mean life expectancy was 11.5 years (9.8 years EVAR, 11.9 years open repair; P [ .09). The 1-year (98% EVAR, 96% open repair), 5-year (86% EVAR, 88% open repair), and 10-year (54% EVAR, 75% open repair) survival did not differ between EVAR and open repair (P [ .16). Long-term survival (78% EVAR, 85% open repair; P [ .09) and reintervention rates (12% EVAR, 16% open repair; P [ .80) did not differ. No late aneurysm rupture or aneurysm-related deaths were observed. The most common causes of long-term mortality were malignant disease and cardiovascular events. Reinterventions in the open repair group were exclusively laparotomy related (incisional hernia repairs), whereas all reinterventions in the EVAR group were aortic related, including one conversion to open repair. Conclusions: After elective aneurysm repair, younger patients have a moderate life expectancy related to malignant disease and cardiovascular health. EVAR offers durability and long-term survival similar to those with open repair in these younger patients as long as aneurysm anatomy and IFU are adhered to. (J Vasc Surg 2015;61:636-41.)
Since its first report in 1991,1 endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms (AAAs) has become an established and preferred method of treatment in many patients. Several randomized controlled trials comparing EVAR and open repair have revealed an early survival advantage, a lower perioperative morbidity rate, and a shorter hospital stay with EVAR.2-4 As a result,
From the Division of Vascular Surgery, London Health Sciences Centre and The University of Western Ontario. Author conflict of interest: none. Presented at the Twenty-eighth Annual Meeting of the Eastern Vascular Society, Boston, Mass, September 11-14, 2014. Reprint requests: Thomas L. Forbes, MD, University Health Networke Toronto General Hospital, 200 Elizabeth St, Eaton North 6-222, Toronto, ON, Canada, M5G 2C4 (e-mail: [email protected]). The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. 0741-5214 Copyright Ó 2015 by the Society for Vascular Surgery. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jvs.2014.10.012
636
EVAR has become the most frequent method of elective repair of AAAs at most vascular centers, including ours.5 However, some believe that EVAR is not the preferred approach in younger patients with long life expectancies because of concerns about durability, reinterventions, surveillance requirements, and lack of an early survival advantage. A study using information from the National Surgical Quality Improvement Program revealed similar in-hospital mortality rates between open repair (0.4%) and EVAR (1.1%) in patients younger than 60 years.6 Reintervention rates are also a concern in younger patients, although some randomized trial information suggests similar reintervention rates between EVAR and open repairs when laparotomyrelated reinterventions are included in the open group.7 Two reports8,9 from England suggest that young patients with aneurysms do not have the life expectancy of nonaneurysm patients, which is pertinent in considering the durability of any repair and surveillance requirements. These studies, however, did not investigate the role of aneurysm anatomy or adherence to the devices’ instructions for use (IFU) criteria, which are known to be key determinants of EVAR durability and risk of reintervention.10
JOURNAL OF VASCULAR SURGERY Volume 61, Number 3
The purpose of this study was to review our center’s early and late outcomes with elective repair of AAAs in young patients (60 years of age or younger at the time of repair) and to analyze aneurysm anatomy and its possible role in EVAR durability. METHODS A retrospective review of a prospectively collected database at our university-affiliated medical center was performed to identify all patients who were 60 years of age or younger at the time of their elective endovascular or open repair of an AAA between 2000 and 2013. Missing information was obtained through chart review. Long-term mortality and information about reinterventions were confirmed by contacting individual patients or family members. All reinterventions related to the initial AAA repair were reviewed, including all aortic and access-related procedures, laparotomies for bowel obstructions and incisional hernia repairs, and femoral-femoral crossover complications (infection, thrombosis). Superficial wound infections were not included and are not the focus of this study. Exclusion criteria included ruptured or symptomatic aneurysms, fenestrated endografts, prior infrarenal aortic surgery, aneurysm requiring suprarenal clamping or renal or mesenteric artery procedures, connective tissue disorders, mycotic aneurysms, and aneurysms associated with aortic dissections. Preoperative anatomic measurements were performed by centerline measurements and commercially available three-dimensional reconstruction software (TeraRecon, San Mateo, Calif). A composite list of IFU criteria was defined as suprarenal aortic angulation <60 degrees, infrarenal aortic neck angulation <75 degrees, aneurysm infrarenal neck length >15 mm and diameter between 18 and 32 mm, and common iliac artery distal fixation length >10 mm and diameter between 8 and 25 mm. These patients received endovascular or open repair in a nonrandomized fashion at the discretion of their attending surgeon after consideration of such issues as aneurysm anatomy, patient comorbidities, and patient preference. Open repair was performed with a midline incision and transperitoneal approach with an infrarenal clamp and a straight or bifurcated graft, depending on the extent of the aneurysm, and any coexisting aortoiliac occlusive disease with a woven tube or bifurcated graft. EVAR was performed with one of the following stent grafts by bilateral groin cutdowns: Talent (Medtronic, Minneapolis, Minn), Endurant (Medtronic), or Zenith (Cook Medical, Bloomington, Ind). After EVAR procedures, postoperative surveillance consisted primarily of computed tomography (CT) scans during the earlier years of the study but more recently transitioned to annual ultrasound examinations following evidence of aneurysm sac regression and absence of endoleak on the 1-year CT scan. It was recommended that patients receive a CT scan 5 years after open repair by their primary care physicians. These CT scans were not reviewed for this study. Statistical analysis was performed with SPSS Statistics version 20.0 (IBM, Armonk, NY). Comparison of categorical
Lee et al 637
Table I. Patient demographic and endovascular aneurysm repair (EVAR) details
Mean age, years % Male Coronary artery disease Previous PCI Previous CABG Left ventricular dysfunction Arrhythmia HTN DM Smoking Current Previous smoker COPD CHOL Dialysis CKD Configuration for EVAR Bifurcated Aortouni-iliac Stent graft type Medtronic Talent Medtronic Endurant Cook Zenith
EVAR (n ¼ 50), No. (%)
Open (n ¼ 119), No. (%)
57.1 92 15 (30) 6 9 8 (16) 5 (10) 43 (86) 14 (28)
56.6 92 29 (24) 8 21 7 (6) 6 (5) 82 (69) 27 (23)
.2 1.00 .50
23 18 12 36 1 4
51 56 17 70
.77 .16 .32 .14 .30 1.000
(46) (36) (24) (72) (2) (8)
(43) (47) (21) (59) 0 10 (8)
P value
.04 .31 .03 .50
36 (72) 14 (28) 13 (26) 13 (26) 24 (48)
CABG, Coronary artery bypass graft; CHOL, cholesterol; CKD, chronic kidney disease; COPD, chronic obstructive pulmonary disease; DM, diabetes mellitus; HTN, hypertension; PCI, percutaneous coronary intervention. Coronary artery disease is defined as previous documented myocardial infarction treated medically, percutaneous coronary intervention, or coronary artery bypass graft. Left ventricular dysfunction is defined as ejection fraction <55%. Chronic obstructive pulmonary disease is defined as forced expiratory volume in 1 second (FEV1) <80% and FEV1/forced vital capacity <0.70. Chronic kidney disease is defined as estimated glomerular filtration rate <60 mL/min/1.73 m2.
variables was done by the c2 test and Fisher exact test, whereas continuous variables were analyzed by nonpaired t-tests. Long-term survival and freedom from reintervention were determined by life-table analysis and Kaplan-Meier curves and log-rank tests. Results are reported as mean 6 standard deviation, and the level of statistical significance was set at P < .05. Individual patient consent for study inclusion was not obtained or required, and this study received approval from the University of Western Ontario Research Ethics Board for Health Sciences Research Involving Human Subjects. RESULTS Initially, 203 consecutive patients aged 60 years or younger who underwent AAA repair between January 2000 and December 2013 were identified. The final study cohort included 169 patients after 34 patients were excluded (two with connective tissue disorders, three with mycotic aneurysms, two with aortic dissections, and 27 with ruptured aneurysms). Of these 169 patients, 50 (30%) underwent EVAR and 119 (70%) received open repair. Mean age was 56.7 6 2.8 years and 92% of patients were male, with no difference between groups. The two treatment groups were similar with respect to the incidence
JOURNAL OF VASCULAR SURGERY March 2015
638 Lee et al
Table II. Preoperative anatomic data for endovascular aneurysm repair (EVAR) and open repair groups
Suprarenal angulation Infrarenal angulation Neck length Neck diameter AAA maximum diameter Right CIA length Right CIA diameter Left CIA length Left CIA diameter Outside of IFU criteria Aneurysm angulation Neck anatomy Iliac artery anatomy
EVAR (n ¼ 39)
Open (n ¼ 38)
4.2 16.9 30.6 22.6 56.4 48.7 15.1 48.9 14.5 5 0 4 1
13.0 28.7 19.9 21.7 63.7 51.5 19.0 51.2 17.0 16 2 9 5
Table III. Early in-hospital results
P value .004 .005 <.001 .22 .02 .51 .07 .56 .16 .004
AAA, Abdominal aortic aneurysm; CIA, common iliac artery; IFU, instructions for use.
of preoperative coronary artery disease, arrhythmia, diabetes, smoking, pulmonary disease, and renal insufficiency (Table I). However, patients receiving endovascular repair were more likely to suffer from hypertension (EVAR, 86%; open repair, 69%; P ¼ .03) and poor left ventricular function (EVAR, 16%; open repair, 6%; P ¼ .04). In the EVAR group, 36 patients received bifurcated devices and 14 were treated with aortouni-iliac endografts. The majority of the aortouni-iliac grafts were placed early during this experience by one of our surgeons and seldom after 2005. Endografts used included 13 Medtronic Talent (26%), 13 Medtronic Endurant (26%), and 24 Cook Zenith (48%). Preoperative anatomic data were collected from 39 patients from the EVAR group and 38 patients from the open repair group as summarized in Table II. Unfortunately, the remaining preoperative CT scans were unavailable for review. Preoperative anatomic information was more commonly available once it was included in our database after 2005. The open repair group had significantly larger suprarenal (open repair, 13.0 degrees; EVAR, 4.2 degrees; P ¼ .004) and infrarenal (open repair, 28.7 degrees; EVAR, 16.9 degrees; P ¼ .005) neck angles. The mean infrarenal neck length was shorter in the open repair group (open repair, 19.9 mm; EVAR, 30.6 mm; P < .001), and maximum aneurysm diameter was larger in the open repair group (open repair, 63.7 mm; EVAR, 56.4 mm; P ¼ .02). There was no significant difference between the groups regarding infrarenal neck diameter and common iliac artery length or diameter. Only five patients did not meet all IFU criteria in the EVAR group (13%) compared with 16 in the open repair group (42%; P ¼ .004). Of the five patients in the EVAR group, one patient had a right common iliac artery diameter of 26 mm, one patient had a neck diameter of 14 mm, and three patients had neck lengths <15 mm. One of the five non-IFU EVAR patients required open conversion for chronic thrombosis of an aortouni-iliac stent graft.
EVAR (n ¼ 50), No. (%)
Open (n ¼ 119), No. (%)
0 (0) 1 (2) 1 0 3.2
3 (2.5) 3 (2.5) 0 3 7.9
In-hospital mortality rate In-hospital reintervention rate Endovascular reintervention Surgical reintervention Length of hospital stay, days
P value .56 .66 <.001
EVAR, Endovascular aneurysm repair.
Table IV. Long-term survival and reintervention rates
Survival rate, % (No.) Cause of mortality AAA-related death Non-AAA-related death Unknown Lost to follow-up Mean follow-up length, months Reintervention rate, % (No.) Endovascular Surgical
EVAR (n ¼ 50)
Open (n ¼ 116)
78 (39)
85 (86)
0 7 4 0 62.5 12 (6) 2 4
0 13 2 15 78.2 16 (16) 0 16
AAA, Abdominal aortic aneurysm; EVAR, endovascular aneurysm repair.
There were three in-hospital deaths (2.5%) in the open repair group and none in the EVAR group (P ¼ .6). The overall in-hospital mortality rate was 1.8% (Table III). The deaths in the open repair group were due to respiratory failure in two cases and cardiac arrest in the other. Length of stay was significantly shorter after EVAR (EVAR, 3.2 days; open repair, 7.9 days; P < .001). One patient (2%) in the EVAR group required early reintervention during the index admission (renal artery stent for partial coverage of a renal artery). Three patients (2.5%) required early reintervention during the index admission in the open group (lower extremity embolectomy in two cases and repair of a wound dehiscence in the other). These early reintervention rates did not differ between the two groups (P ¼ .66). Mean length of follow-up for the EVAR and open repair groups were 62.5 months (median, 57.7 months) and 78.2 months (median, 86.8 months), respectively. Overall mean life expectancy was 11.5 years, and there was no difference between the two groups (EVAR, 9.8 years vs open repair, 11.9 years; P ¼ .09). There was also no difference in long-term survival rate between the two groups (EVAR, 78% vs open repair, 85%; P ¼ .09; Table IV). Kaplan-Meier survival analysis showed that the survival rate at 1 year (EVAR 98% vs open repair 96%), 5 years (EVAR, 86% vs open repair, 88%), and 10 years (EVAR, 54% vs open repair, 75%) did not differ between EVAR and open groups (P ¼ .16; Fig 1). Most common causes of long-term mortality were malignant disease and cardiovascular-related deaths (Table V). There were no
JOURNAL OF VASCULAR SURGERY Volume 61, Number 3
Fig 1. Kaplan-Meier survival curve for endovascular aneurysm repair (EVAR) group vs open repair group (log-rank, P ¼ .09). Standard error <10% for all intervals for open group; in EVAR, only 96 and 120 months over >10% at 11% and 12%.
aneurysm ruptures or late aneurysm-related deaths in either repair group. The long-term reintervention rate was not significantly different between the two groups (EVAR 12% vs open repair 16%; P ¼ .80; Fig 2). The majority of reinterventions in the open group were incisional hernia repairs. In contrast, all reinterventions in the EVAR group were related to the initial aneurysm repair (Table V). Two patients suffered from thrombosis of an endograft limb (one patient with aortouni-iliac and one with bifurcated endograft), resulting in an axillary-femoral bypass and femoral-femoral crossover graft. There were no instances of crossover graft thrombosis, although one crossover graft had to be removed because of infection. During surveillance, 16% of patients were observed to have a type II endoleak at some point. However, there were no instances of sac expansion, so none of these endoleaks were intervened on or resulted in adverse sequelae. The only reintervention for an endoleak was for a type Ib endoleak, repaired with an iliac extension. One patient required conversion to open repair because of complete thrombosis of a bifurcated endograft 2 months after the initial procedure. There were no mortalities related to these reinterventions. DISCUSSION This retrospective single-center study demonstrates that patients 60 years of age or younger do equally well after elective endovascular or open repair of their AAA with similar chances of survival during the perioperative period (no early deaths in the EVAR group) and at 1, 5, and 10 years after their initial repair, despite higher rates of hypertension and left ventricular dysfunction in patients undergoing EVAR. Causes of death were predominantly due to malignant diseases and non-aneurysm-related cardiovascular events. Chances of additional procedures did
Lee et al 639
not depend on method of repair when all aortic and nonaortic reinterventions were considered. A major caveat of these findings is that the large majority of EVAR patients fit the IFU of available endografts, which is known to be an important predictor of EVAR durability.10 By following the IFU, our EVAR group comprised patients with aortic anatomy that should predict excellent short- and longterm results. There have been some concerns regarding EVAR in younger patients, including a questionable early survival benefit and durability concerns in these supposedly goodrisk patients with long life expectancies. We failed to show a perioperative survival advantage with EVAR, with an overall in-hospital mortality rate of 1.8% in these patients 60 years of age or younger (no in-hospital deaths after EVAR). However, our EVAR patients were somewhat disadvantaged with more frequent instances of hypertension and compromised left ventricular function and might represent a higher risk group than our open repair patients. These findings are similar to those of the randomized Anevrysme de l’aorte abdominale: Chirurgie vs Endoprothese (ACE) trial11 of low-risk patients and two recent and similar reports from England examining patients 65 years of age or younger that also reported very low in-hospital mortality rates (0.6% and 3.7%) that did not differ between methods of repair.8,9 There is increased evidence that young AAA patients do not have the same life expectancy as patients without aneurysms. In a recent follow-up report from the Dutch Randomized Endovascular Aneurysm Management (DREAM) trial, one third of patients had died 6 years after their repair, with age older than 70 years, cardiovascular disease, and smoking being predictive of poor survival and statin use being protective.12 When analysis was limited to patients 65 years of age or younger, the group from Nottingham observed that 40% of patients died after a median followup of 77 months (6.5 years).8 After review of the English National Health Service data set, the St. George’s group reported that AAA patients were disadvantaged, with a 5year survival rate of 67.4% compared with 81.1% for controls.13 These experiences and others suggest that AAAs reflect a degree of increased cardiovascular risk with respect to life expectancy and that durability of EVAR in younger patients may not be of any more concern than with older patients. However, our study cohort exhibited better 5-year survival rates (86% and 88%) than in these reports, which suggests that longer life expectancy and procedure durability are issues in these younger patients. We are unsure of the reasons for this improved survival in our patients, whether it is related to such unstudied factors as statin use, as was found in the DREAM trial,12 or because our study examined younger patients (60 years of age and younger) compared with the other studies.8,9 Although it is not statistically significant, there was a trend toward improved 10-year survival after open repair compared with EVAR (75% vs 54%). This may reflect the increased cardiovascular risk burden exhibited by our EVAR cohort.
JOURNAL OF VASCULAR SURGERY March 2015
640 Lee et al
Table V. Causes of long-term mortality and reinterventions EVAR Cause of death
3 1 3 4
Reintervention details
1 1 1 1
Open
Cancer Gastrointestinal Cardiac Unknown
Axillary-femoral artery bypass for thrombosed stent graft Excision of femoral-femoral crossover graft for infection Open conversion from thrombosed stent graft Femoral-femoral crossover graft for stent graft limb thrombosis 1 External iliac artery angioplasty and stent 1 Repair of type Ib endoleak
1 Perforated bowel 8 Cancer 3 Cardiac 1 Trauma 2 Unknown 13 Incisional hernia repairs 1 Femoral-femoral crossover graft for limb thrombosis 1 Thrombectomy of graft and distal bypass 1 Ilioprofunda bypass
EVAR, Endovascular aneurysm repair.
Fig 2. Freedom from reintervention for elective endovascular aneurysm repair (EVAR) group vs elective open repair group (logrank, P ¼ .80). Standard error <10% for all intervals.
With potentially longer life expectancies, there has also been concern about higher reintervention rates in younger patients after EVAR compared with open repair. This has been especially evident when only aortic or aneurysm-related reinterventions are included. However, when we examined all reinterventions, including laparotomy-related procedures for bowel obstructions or incisional hernias, there was no difference in risk of reintervention between repair methods (EVAR, 12%; open repair, 16%). This is consistent with the Nottingham experience that studied patients 65 years of age or younger.8 In contrast, the Leicester group, with a similar study cohort, observed more frequent reinterventions after EVAR.9 However, half of the reinterventions in the EVAR group were secondary to type I endoleaks. They did not report anatomic measurements, but their finding could reflect anatomic selection factors, such as infrarenal neck anatomy, that are predictive of attachment site failures.10,14 By adhering to endograft IFU, our study reveals that these attachment site endoleaks can be generally
prevented, a finding that has been observed in larger studies.10,14-16 The majority of reinterventions in our EVAR cohort were related to ischemic or thrombotic complications rather than to endoleaks, raising the possibility that EVAR could offer a lower reintervention rate if these issues were reduced with better patient selection or adjunct techniques. This study differs from two similar recent reports from England8,9 in that preoperative anatomic information is included. It has been previously demonstrated that more than half of patients in the United States who undergo EVAR have anatomy outside the endograft’s IFU10 and exhibit higher rates of graft thrombosis, reintervention, and sac enlargement.17 Because IFU are specific to different devices, we used a composite set that included infrarenal aneurysm neck length of 15 mm or longer as shorter necks are associated with an increased risk of type I endoleaks in the short and midterms.15 Some newer generation endografts, such as some used in this study, have shorter neck lengths as part of their IFU. Regardless, these results validate our approach to offer EVAR to young patients only if their anatomy adheres to the IFU for a durable repair over the longer term. Those young patients with aneurysm anatomy outside the IFU are better served with open repair to avoid aortic-specific reinterventions. These include the larger aneurysms that were generally treated with open repair at our center and are less inclined to have anatomy that adheres to the IFU. Larger aneurysms (>6 cm) are known to have a higher risk of rupture, conversion to open repair, and aneurysm-related mortality after EVAR.18,19 Our study has the limitations inherent in a nonrandomized, single-center, retrospective analysis of a moderate number of patients. No patients were lost to follow-up in the EVAR group, but 15 patients were lost to follow-up in the open repair group. During long-term follow-up, there were six patients in whom the cause of death was undetermined; four were in the EVAR group and two in the open repair group. None of these patients in the EVAR group had endoleaks, graft migration, or kinking in the most recent CT scans performed before their death. Last,
JOURNAL OF VASCULAR SURGERY Volume 61, Number 3
anatomic data were available in only 78% of the EVAR patients because the other 22% had their preoperative CT scans at a different institution or their CT scans were not available. The limited preoperative anatomic information for both repair groups is a limitation. In addition, given the nonrandomized comparison between groups, differences in unaccounted for confounders (other comorbidities, functional status, statin use) between the two groups may have influenced the results. CONCLUSIONS Open repair or EVAR in the treatment of young patients with AAAs has been a topic of debate because of the concern of durability and reintervention risk after endovascular repair. This study shows that younger patients who undergo elective EVAR have survival, durability, and reintervention rates similar to those of open repair patients (despite higher rates of some cardiac comorbidities), as long as aneurysm anatomy is considered and endograft IFU are strictly adhered to. These young aneurysm patients have a moderate life expectancy related primarily to malignant disease and cardiovascular events but similar chances of long-term survival regardless of the method of initial repair. Especially in higher risk younger patients, EVAR should be the method of repair in anatomically suitable patients, with similar outcomes expected at 5 and 10 years compared with open repair. AUTHOR CONTRIBUTIONS Conception and design: KL, TF Analysis and interpretation: KL, LD, AP, GD, TF Data collection: KL, ET Writing the article: KL, TF Critical revision of the article: KL, ET, LD, AP, GD, TF Final approval of the article: KL, ET, LD, AP, GD, TF Statistical analysis: KL, ET Obtained funding: Not applicable Overall responsibility: TF REFERENCES 1. Parodi JC, Palmaz JC, Barone HD. Transfemoral intraluminal graft implantation for abdominal aortic aneurysms. Ann Vasc Surg 1991;5: 491-9. 2. Greenhalgh RM, Brown LC, Kwong GP, Powell JT, Thompson SG; EVAR trial participants. Comparison of endovascular aneurysm repair with open repair in patients with abdominal aortic aneurysm (EVAR trial 1), 30-day operative mortality results: randomised controlled trial. Lancet 2004;364:843-8. 3. Lederle FA, Freischlag JA, Kyriakides TC, Padberg FT Jr, Matsumura JS, Kohler TR, et al. Outcomes following endovascular vs open repair of abdominal aortic aneurysm: a randomized trial. JAMA 2009;302:1535-42.
Lee et al 641
4. Prinssen M, Verhoeven EL, Buth J, Cuypers PW, van Sambeek MR, Balm R, et al. A randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms. N Engl J Med 2004;351:1607-18. 5. Chadi SA, Rowe BW, Vogt KN, Novick TV, Harris JR, Derose G, et al. Trends in management of abdominal aortic aneurysms. J Vasc Surg 2012;55:924-8. 6. Gupta PK, Ramanan B, Lynch TG, Gupta H, Fang X, Balters M, et al. Endovascular repair of abdominal aortic aneurysm does not improve early survival versus open repair in patients younger than 60 years. Eur J Vasc Endovasc Surg 2012;43:506-12. 7. Lederle FA, Freischlag JA, Kyriakides TC, Matsumura JS, Padberg FT Jr, Kohler TR, et al. Long-term comparison of endovascular and open repair of abdominal aortic aneurysm. N Engl J Med 2012;367:1988-97. 8. Altaf N, Abisi S, Yong Y, Saunders JH, Braithwaite BD, MacSweeney ST. Mid-term results of endovascular aortic aneurysm repair in the young. Eur J Vasc Endovasc Surg 2013;46:315-9. 9. Sandford RM, Choke E, Bown MJ, Sayers RD. What is the best option for elective repair of an abdominal aortic aneurysm in a young fit patient? Eur J Vasc Endovasc Surg 2014;47:13-8. 10. Schanzer A, Greenberg RK, Hevelone N, Robinson WP, Eslami MH, Goldberg RJ, et al. Predictors of abdominal aortic aneurysm sac enlargement after endovascular repair. Circulation 2011;123:2848-55. 11. Becquemin JP, Pillet JC, Lescalie F, Sapoval M, Goueffic Y, Lermusiaux P, et al. A randomized controlled trial of endovascular aneurysm repair versus open surgery for abdominal aortic aneurysms in low- to moderate-risk patients. J Vasc Surg 2011;53:1167-73.e1. 12. de Bruin JL, Baas AF, Heymans MW, Buimer MG, Prinssen M, Grobbee DE, et al. Statin therapy is associated with improved survival after endovascular and open aneurysm repair. J Vasc Surg 2014;59:39-44.e1. 13. Karthikesalingam A, Bahia SS, Patterson BO, Peach G, Vidal-Diez A, Ray KK, et al. The shortfall in long-term survival of patients with repaired thoracic or abdominal aortic aneurysms: retrospective casecontrol analysis of hospital episode statistics. Eur J Vasc Endovasc Surg 2013;46:533-41. 14. Hobo R, Sybrandy JE, Harris PL, Buth J; EUROSTAR Collaborators. Endovascular repair of abdominal aortic aneurysms with concomitant common iliac artery aneurysm: outcome analysis of the EUROSTAR Experience. J Endovasc Ther 2008;15:12-22. 15. Leurs LJ, Kievit J, Dagnelie PC, Nelemans PJ, Buth J; EUROSTAR Collaborators. Influence of infrarenal neck length on outcome of endovascular abdominal aortic aneurysm repair. J Endovasc Ther 2006;13:640-8. 16. Vallabhaneni R, Farber MA, Schneider F, Ricco JB. Debate: whether young, good-risk patients should be treated with endovascular abdominal aortic aneurysm repair. J Vasc Surg 2013;58:1709-15. 17. Abbruzzese TA, Kwolek CJ, Brewster DC, Chung TK, Kang J, Conrad MF, et al. Outcomes following endovascular abdominal aortic aneurysm repair (EVAR): an anatomic and device-specific analysis. J Vasc Surg 2008;48:19-28. 18. Peppelenbosch N, Buth J, Harris PL, van Marrewijk C, Fransen G; EUROSTAR Collaborators. Diameter of abdominal aortic aneurysm and outcome of endovascular aneurysm repair: does size matter? A report from EUROSTAR. J Vasc Surg 2004;39:288-97. 19. Zarins CK, Crabtree T, Bloch DA, Arko FR, Ouriel K, White RA. Endovascular aneurysm repair at 5 years: does aneurysm diameter predict outcome? J Vasc Surg 2006;44:920-9; discussion: 929-31.
Submitted Jul 30, 2014; accepted Oct 8, 2014.