What Is the Long-Term Durability Of Open Abdominal Aortic Aneurysm Repair?

Objective:In multiple comparisons of open(OR)versus Endovascula(EVAR)repair for abdominal aortic aneurysm(AAA), the prior assumption that OR produced superior durability has been challenged by advocates of EVAR. While focus on EVAR reintervention has been intense, few contemporary studies document late outcomes after OR, which is the goal of this study.
Methods: From 1/1994-12/1998(>5year follow-up), 579patients underwent OR. Follow-up(mean 87months), surveillance imaging(CT/MRI)was obtained on 152 of the 269(57%)alive patients. Endpoints included freedom from graft-related complications and survival(Kaplan-Meier); predictive factors were determined by multivariate analysis.
Results: Mean age 73yrs, male76%, 10%renal insufficiency(RI)(creatinine>1.5mg/dl)and COPD12%. Aneurysms were juxtarenal in 105(18%)patients, 39(6.7%)were ruptured at presentation and 52% had bifurcated grafts placed. 30-day mortality was 4.4%(elective OR=3.3%)and the median hospital stay was 8days. Post-operative complications occurred in 86(14.9%)patients. Predictors of post-operative complications included: rupture(Hazard Ratio(HR)4.3, p<0.001)and renal insufficiency(HR2.5, p=0.02). Actuarial survival was 68.9%+1.9 and 43.1%+2.3 at 5 and 10 years respectively. Negative predictors of long-term survival included: age(HR1.1, p<0.001), juxtarenal aneurysm(HR1.4, p=0.03), rupture(HR2.1, p=0.001) and RI(HR1.5, p=0.04). Freedom from graft-related reintervention was 98.2%+0.8 and 94.3%+3.4 at 5 and 10 years respectively. Predictors of reintervention included: juxtarenal aneurysms(HR7.6, p=0.02) and rupture(HR14.3, p=0.001). 11/152(7.2%)patients had late graft complications on follow-up imaging (mean 7.2years). Findings included 7 anastomotic pseudoaneurysms (4 were repaired), 4 graft limb occlusions and 1 graft infection (one patient had all 3 findings). Aneurysms were identified in noncontiguous arterial segments in 68/152(45%)patients(25 proximal to graft, 43 distal)and 29(19%)patients had multiple aneurysms. Predictors of multiple aneurysms include: age at presentation(HR1.0, p=0.02), history of MI(HR8.7, p=0.001)and renal insufficiency(HR7.3, p=0.04).
Conclusion: OR remains a safe and durable option for the management of AAA with an excellent associated five-year survival. However, with sufficient duration of follow-up, the re-intervention rate approaches that reported for EVAR. In addition ,continued surveillance after OR is appropriate and should be directed towards detection of other aneurysms.