One-year Reoperation or Reintervention After Open Aortic Aneurysm Repair Is Increasing

Endovascular abdominal aortic aneurysm (AAA) repair (EVAR) is traditionally viewed as the less morbid repair compared with open repair, but associated with a higher risk of subsequent reinterventions. However, an up-to-date analysis of complications after aneurysm repair has not been well characterized, especially in recent cohorts. Using Medicare-linked data from the Vascular Quality Initiative linked to Medicare claims through the Vascular Implant Surveillance and Interventional Outcomes Network (VISION), we identified all patients who underwent aortic aneurysm repair between 2012 and 2017. We stratified patients by type of aneurysm repair (EVAR vs open repair) as well as the year they underwent surgery. We analyzed differences in aneurysm characteristics, comorbidities as well as complications. Our primary end point was the risk of aneurysm-related vascular reinterventions or reoperation after the initial aortic repair. A total of 15,770 patients who underwent aortic aneurysm repair were included in the analysis, the majority of which received EVAR (EVAR, 13,496 [86%]; open, 2274). EVAR patients were typically older (76.5 years for EVAR vs 74 years for open repair; P = .03), and were more likely to have heart failure (12.5% vs 7.8%; P = .03), coronary artery disease (28.5% vs 26.3%), and diabetes (20.3% vs 18%). Women more frequently underwent open repair (33% vs 20%; P = .06). Most patients (94%) underwent AAA repair on an elective basis. Symptomatic patients (8%) were more likely to receive open repair (12%) compared with EVAR (6.5%) (P = .04). The incidence of reintervention/operation among EVAR patients was low and slightly decreased from 2.5% in 2012 to 2.0% in 2017. Conversely, there was a relative increase in risk of reintervention/operation for open repair, from 1.6% in 2012, to 3.6% in 2017 (Table I). The hazard ratio for reintervention or reoperation after open AAA repair in 2016 and 2017 was 3.29 times higher (95% confidence interval, 1.55-6.96; P < .001) than it was in 2012 and 2013, even after adjusting for age, gender, comorbidities, and aneurysm characteristics. EVAR, however, was associated with a trend toward decreased risk of re-intervention/operation during this same time period (Table II). The need for reintervention or reoperation with the first year after open AAA repair has increased more than three-fold in the last 5 years when adjusting for clinical and anatomic characteristics, whereas EVAR has remained relatively unchanged. Even though open AAA repair occurs in fewer in one in five aneurysms, educational initiatives should be refined to ensure training programs can provide safe open aortic surgery in the EVAR era.Table IEstimated risks of reintervention/reoperation at 1 year2012-20132014-20152016-2017Open1.6% (0.9%-2.9%)2.9% (1.8%-4.6%)3.6% (2.4%-5.6%)EVAR2.5% (2.0%-3.2%)2.6% (2.1%-3.2%)2.0% (1.6%-2.5%)EVAR, Endovascular aneurysm repair. Open table in a new tab Table IICox regression of risk of reintervention/reoperation2012-20132014-20152016-2017OpenRef1.93 (0.92-4.06)3.29 (1.55-6.96)EVARRef1.04 (0.79-1.37)0.85 (0.64-1.13)EVAR, Endovascular aneurysm repair.We used 2012-2013 as the referent year. Covariates adjusted for age, gender, comorbidities, and aneurysm characteristics such as size, neck angle, iliac diameter, and occlusive disease. Open table in a new tab