Decrease in total aneurysm-related deaths in the era of endovascular aneurysm repair

Abstract

Objective: With the expansion of elective abdominal aortic aneurysm (AAA) repair after the introduction of endovascular aneurysm repair (EVAR), there is a concern that even with a lower operative mortality there could be an increasing number of aneurysm-related deaths. To evaluate this, we looked at national trends in AAA repair volume as well as mortality rates after intact and ruptured AAA repair encompassing the introduction of EVAR.

Methods: Patients with intact or ruptured AAA undergoing open repair or EVAR and all those with a diagnosis of ruptured AAA were identified within the 1993 to 2005 Nationwide Inpatient Sample database using International Classification of Diseases, 9th Revision, diagnosis and procedure codes. The number of repairs, number of rupture diagnoses without repair, number of deaths, and associated mortality rates were measured for each year of the database. Outcomes (mean annual volumes) were compared from the pre-EVAR era (1993 to 1998) with the post-EVAR era (2001 to 2005).

Results: Since its introduction, EVAR increased steadily and accounted for 56% of repairs yet only 27% of the deaths for intact repairs in 2005. The mean annual number of intact repairs increased from 36,122 in the pre-EVAR era to 38,901 in the post-EVAR era, whereas the mean annual number of deaths related to intact AAA repair decreased from 1693 pre-EVAR to 1207 post-EVAR (P < .0001). Mortality for all intact AAA repair decreased from 4.0% to 3.1% (P < .0001) pre-EVAR and post-EVAR, but open repair mortality was unchanged (open repair, 4.7% to 4.5%, P = .31; EVAR, 1.3%). During the same time, the mean annual number of ruptured repairs decreased from 2804 to 1846, and deaths from ruptured AAA repairs decreased from 2804 to 1846 (P < .0001). Mortality for ruptured AAA repair decreased from 44.3% to 39.9% (P < .0001) pre-EVAR and post-EVAR (open repair, 44.3% to 39.9%, P < .001; EVAR, 32.4%). The overall mean annual number of ruptured AAA diagnoses (9979 to 7773, P < .0001) and overall mean annual deaths from a ruptured AAA decreased post-EVAR (5338 to 3901, P < .0001).

Conclusion: Since the introduction of EVAR, the annual number of deaths from intact and ruptured AAA has significantly decreased. This coincided with an increase in intact AAA repair after the introduction of EVAR and a decrease in ruptured AAA diagnosis and repair volume.

Figure 1

Abdominal aortic aneurysm repairs from 1993 to 2005 in the Nationwide Inpatient Sample. There was an increase in repairs for intact aneurysms but a decrease in repairs for ruptured aneurysms over time.

Figure 2

Annual deaths from 1993 to 2005 after abdominal aortic aneurysm repair (total, ruptured, and elective). An asterisk indicates that the decline in deaths after the introduction of EVAR was greater than the decline prior to EVAR (P < .0001).

Figure 3

Intact aortic aneurysm repairs from 1993 to 2005.

Figure 4

Ruptured abdominal aortic aneurysms from 1993 to 2005 after abdominal aortic aneurysm repair (total diagnoses, repairs, total deaths, repair deaths). An asterisk indicates that the decline in diagnoses, repairs, and deaths after the introduction of EVAR was greater than the decline prior to EVAR (P < .0001).