Longitudinal Analysis of Outcomes for Open Aortic Reconstructions: Has the “Endovascular Era” Impacted Mortality?

Objective: Several observational studies in the late 1990’s revealed progressive decline in in-hospital mortality after open aortic reconstructions. In recent years, however, endovascular therapies have largely replaced open aortic procedures, which are now reserved for advanced disease that is neither amenable to nor appropriate for endovascular treatments. The purpose of this study was to investigate changes in in-hospital mortality after aorto-bifemoral bypass (AFB) and open repair of abdominal aortic aneurysms (AAAs).
Methods: The Nationwide Inpatient Sample (NIS) was queried to identify open repairs of AAAs and ABFs during the years 1997-2006. Risk stratification was based on comorbidities and the Charlson Comorbidity Index (CCI). Weighted univariate and multivariate logistic regression analyses were used to determine changes in risk-adjusted in-hospital mortality.
Results: The number of open AAA repairs and AFBs has significantly decreased from 1997 to 2006 (35,351 to 12,191 and 20,628 to 12,965, respectively). Although stable after AFBs (4.1% vs. 4.0%, P=.69), in-hospital mortality has significantly increased after open AAA repairs (from 4.8% to 5.9%, P <.001) with a corresponding 25% increased risk for in-hospital death (odds ratio[OR],1.25; 95% confidence interval[CI],1.17 -1.33). Of note, in-hospital mortality after open AAA repairs rose more dramatically in teaching hospitals (4.8% in 1997 vs. 6.6% in 2006,P<.001) compared to non-teaching hospitals (4.7% in 1997vs. 5.0% in 2006;P=.28). After adjusting for age, sex, hospital teaching status and comorbidities, multivariate logistic regression revealed an 18% increase in risk-adjusted in-hospital mortality after open AAA repairs (OR 1.18; 95%CI,1.1-1.26) during the study period.
Conclusion: In-hospital mortality after open AAA repairs has significantly increased over the last 10 years in the United States. Such increased in-hospital mortality has occurred primarily in teaching hospitals, which likely reflects the complexity of current open AAA repairs. These data should be considered in current guidelines and health quality measures to reflect changes in the number, complexity and outcomes of these established procedures.