Comparison of long-term survival after open vs endovascular repair of intact abdominal aortic aneurysm among medicare beneficiaries

Context: Endovascular repair of abdominal aortic aneurysm (AAA) compared with open repair increases perioperative survival, but it is not known if it increases longterm survival. Objective: To compare long-term outcomes after open vs endovascular repair of AAA. Design, Setting, and Patients: Retrospective analysis of patients 65 years or older in the Medicare Standard Analytic File, 2003-2007, who underwent isolated repair of intact AAA. Cause of death was determined from the National Death Index. Main Outcome Measures: The primary outcome was all-cause mortality. Secondary outcomes were AAA-related mortality, hospital length of stay, 1-year readmission, repeat AAA repair, incisional hernia repair, and lower extremity amputation. Results: Of 4529 included patients, 703 were classified as having undergone open repair and 3826 as having undergone endovascular repair. Mean and median follow-up times were 2.6 (SD, 1.5) and 2.5 (interquartile range, 2.4) years, respectively. In unadjusted analysis, both all-cause mortality (173 vs 752; 89 vs 76/1000 person-years, P=.04) and AAA-specific mortality (22 vs 28; 11.3 vs 2.8/1000 person-years, P<.001) were higher after open vs endovascular repair. After adjusting for emergency admission, age, calendar year, sex, race, and comorbidities, there was a higher risk of both all-cause mortality (hazard ratio [HR], 1.24 [95% CI, 1.05-1.47]; P=.01) and AAA-related mortality (HR, 4.37 [95% CI, 2.51-7.66]; P<.001) after open vs endovascular repair. The adjusted hospital length of stay was, on average, 6.5 days (95% CI, 6.0-7.0 days, P<.001) longer after open repair (mean, 10.4 days), compared with endovascular repair (mean, 3.6 days). Incidence of incisional hernia repair was higher after open AAA repair (19 vs 23; 12 vs 3 per 1000 person-years; adjusted HR, 4.45 [95% CI, 2.37-8.34, P<.001]), whereas the incidence of 1-year readmission (188 vs 1070; 274 vs 376/1000 person-years; adjusted HR, 0.96 [95% CI, 0.85-1.09, P=.52]), repeat AAA repair (15 vs 93; 9.7 vs 12.3/1000 person-years; adjusted HR, 0.80 [95% CI, 0.46-1.38, P=.42]), and lower extremity amputation (3 vs 25; 1.9 vs 3.3/1000 person-years; adjusted HR, 0.55 [95% CI, 0.16-1.86, P=.34]) did not differ by repair type. Conclusion: Among older patients with isolated intact AAA, use of open repair compared with endovascular repair was associated with increased risk of all-cause mortality and AAA-related mortality.