Midterm survival after endovascular repair of intact abdominal aortic aneurysms is improving over time

OBJECTIVE: There is a growing body of literature raising concerns over the long-term durability of endovascular repair (EVAR) for abdominal aortic aneurysms (AAA), suggesting that long-term outcomes may be better after open AAA repair. However, the data investigating these long-term outcomes largely originate from early in the endovascular era and therefore do not account for increasing clinical experience and technological improvements. We investigated whether four-year outcomes after EVAR and open repair have improved over time. METHODS: We identified all EVARs and open repairs for intact infrarenal AAA within the Vascular Quality Initiative database (2003-2018). We then stratified patients by procedure year into treatment cohorts of four years: 2003-2006, 2007-2010, 2011-2014, and 2015-2018. We used Kaplan-Meier analysis and Cox proportional hazards models to assess whether the survival following EVAR or open repair changed over time. Additionally, we propensity-matched EVAR and open repairs for each time cohort, to investigate whether the relative survival benefit of EVAR over open repair changed over time. RESULTS: We included 42,293 EVARs (increasing from 549 performed between 2003-2006 to 25,433 between 2015-2018) and 5,189 open AAA repairs (increasing from 561 to 2,306). Four-year survival increased for the periods 2003-2006, 2007-2010, 2011-2014, and 2015-2018 following both EVAR (76.6% vs. 79.7% vs. 83.5% vs. 87.3%; P<.001) and open repair (82.2% vs. 85.8% vs. 87.7% vs. 88.9%; P=.026). After risk-adjustment, compared to 2003-2006, hazard of mortality up to four years after EVAR was lower in those performed between 2011-2014 (hazard ratio [HR]: 0.72; 95% confidence interval [CI]: 0.59-0.87; P=.001) and for those performed between 2015-2018 (HR: 0.56; 95%CI: 0.46-0.68; P<.001). In contrast, the risk-adjusted hazard of mortality was similar between open repair cohorts (2011-2014: HR: 0.81 [95%CI: 0.61-1.08; P=.15]; and 2015-2018: HR: 0.86 [95%CI: 0.64-1.17; P=.34]). Finally, in matched EVAR and open repairs, there was no difference in mortality in the first three cohorts, while the hazard of mortality was lower for the 2015-2018 cohort (HR: 0.65; 95%CI: 0.51-0.84; P=.001). CONCLUSION: Four-year survival following EVAR improved in patients treated in more recent years but not following open repair. This finding suggests that mid-term outcomes following EVAR are improving, perhaps due to technological improvements and increased experience, information that should be considered by surgeons and policymakers alike when evaluating the value of contemporary EVAR and open AAA repair