February 26, 2007

Endovascular Repair (EVAR) has a Significantly Lower Perioperative (30-Day) and 1-Year Mortality than Open Surgical Repair (SR) of Infrarenal AAA in the General Population

David A. Rigberg, MD¹, David S. Zingmond, MD, MPH¹, Marcia L. McGory, MD¹, Peter F. Lawrence, MD², Clifford Y. Ko, MD, MPH¹.
¹Center for Surgical Outcomes and Quality, UCLA School of Medicine, ²West Los Angeles Veterans' Administration Medical Center, Los Angeles, CA.

Objectives: Elective repair of AAA has shifted from SR to EVAR in appropriate patients. Reports comparing these methods coming from industry-controlled trials, vascular registries, or individual institutions do not necessarily reflect general population outcomes. We hypothesized that SR has a higher mortality than EVAR in the general population, and that this difference would increase with age and risk.
Methods: Data from the California Office of Statewide Health Planning and Development (OSHPD) were analyzed for the year 2002, the first year for which there is an endovascular AAA repair code. We determined 30-day and 1-year mortality and stratified our findings by age and Charlson Comorbidity Index, a validated means of risk adjustment.
Results: In 2002, 1,486 patients underwent SR and 787 underwent EVAR repair of AAA in California. There was a consistently greater mortality with SR in all age groups and in higher risk patients.

30-Day	Overall	<70 years old	70-79 years old	80+ years old
SR	4.0%	3.1%	3.8%	5.9%
EVAR	1.4%	1.6%	1.4%	1.3%
p-value *	0.0009	NS	0.02	0.006
1-Year
SR	9.9%	5.8%	10.3%	16.3%
EVAR	7.0%	5.4%	6.0%	9.8%
p-value *	0.02	NS	0.02	0.03

*p-value for SR versus EVAR at each age group
Mortality increased with Charlson Comorbidity Index for SR and EVAR patients at 30-days and 1-year. The differences were all statistically distinct (p<0.05).
Conclusion: In the general population, operative and 1-year mortality are higher for SR than EVAR, and these differences increase with age and co-morbidities. However, even older, high risk patients (Charlson >2) have an ~85% 1-year survival; therefore patients in this group may be appropriate candidates for either EVAR or SR.

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