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Endovascular and open repairs have similar long-term mortality for AAA

Clinical Question:
What is the best surgical approach for the repair of abdominal aortic aneurysms?

Bottom Line:
Endovascular repair has lower early mortality rates than open repair, but at 5 years there is no difference in overall mortality, with more ruptures in the endovascular repair group. Endovascular repair is only better than open repair in patients younger than 70 years. (LOE = 1b)

Reference:
Lederle FA, Freischlag JA, Kyriakides TC, et al, for the OVER Veterans Affairs Cooperative Study Group. Long-term comparison of endovascular and open repair of abdominal aortic aneurysm. N Engl J Med 2012;367(21):1988-1997.  [PMID:23171095]

Study Design:
Randomized controlled trial (single-blinded)

Funding:
Government

Allocation:
Concealed

Setting:
Inpatient (any location) with outpatient follow-up

Synopsis:
Abdominal aortic aneurysms can be repaired using either a traditional open approach or an endovascular repair. The latter had better perioperative outcomes in previous studies (N Engl J Med 2010;362:1863-71 and N Engl J Med 2010;362:1881-9), but worse outcomes at 2 years of follow-up. This study reports long-term outcomes from a Veterans Affairs study that randomized 881 patients to receive open repair or endovascular repair. Groups were balanced at the start of the study, allocation was concealed, and outcomes were blindly adjudicated. Of note, 99% of the participants in this study were men. Analysis was by intention to treat and patients were followed up for a mean of 5.2 years. There was no difference in all-cause mortality, with 146 deaths in each group. Thirty-day aneurysm-related mortality was higher in the open surgery group (3.0% vs 0.5%; P = .004; number needed to treat to harm = 40), but not by the end of the study (3.7% to 2.3%; absolute difference = -1.4%; 95% CI, -3.7% to 0.8%). It is worth noting that 2 of 10 deaths in the endovascular repair group were early, compared with 13 of 16 in the open repair group; given a choice, I would take a later death over a perioperative death. Aneurysmal ruptures were rare (only 3 fatal ruptures reported in the study), but were more common in the endovascular repair group (6 vs 0; P = .03) and in some cases occurred more than 5 years after the repair. Subgroup analyses found that endovascular repair had better outcomes for patients younger than 70 years, but worse outcomes in patients older than 70. There also appears to have been a learning curve, with higher mortality in those treated before April 15, 2005.

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