Editor's Choice – Short Term and Long Term Outcomes After Endovascular or Open Repair for Ruptured Infrarenal Abdominal Aortic Aneurysms in the Vascular Quality Initiative

Objective: Repair of ruptured infrarenal abdominal aortic aneurysms (rAAA) has shifted from open surgical (OAR) to endovascular (EVAR) over the last decade. However, the long term impact of EVAR vs. OAR for rAAA has not been well described. Methods: Prospectively collected registry data (Vascular Quality Initiative [VQI]) were analysed retrospectively to identify patients who underwent EVAR or OAR for rAAA (2004–2018). The primary outcome was death (in hospital and overall post-discharge). Inverse probability weighting (IPW) was used to adjust for treatment selection. Poisson regression assessed the number of one year post-discharge re-interventions. Results: In total, 4257 patients receiving EVAR (n = 2389 [56%]) or OAR (n = 1868 [44%]) for rAAA were identified. Patients were predominantly male (n = 3310 [77.8%]) with a mean ± standard deviation age of 72.7 ± 9.6 years; most (n = 2449 [59.4%]) presented with haemodynamic instability. Use of EVAR for rAAA increased from 7.8% in 2004 to 67.2% in 2018. After IPW, OAR was associated with a higher odds of in hospital mortality (odds ratio [OR] 1.76, 95% confidence interval [CI] 1.54–2.01; p < .001), which was confirmed after multivariable logistic regression (OR 2.08, 95% CI 1.76–2.45; p < .001). Multivariable Cox proportional hazards showed that OAR was also associated with increased overall post-discharge mortality among all patients (hazard ratio 1.36, 95% CI 1.23–1.51; p < .001). Within weighted treatment groups, five year survival was significantly different (55% for EVAR vs. 46% for OAR; p < .001). OAR showed a significantly higher risk of one year post-discharge re-interventions (incidence rate ratio 2.10, 95% CI 1.52–2.89; p < .001). Conclusion: Within the VQI, EVAR for rAAA repair has been increasingly adopted with favourable short term outcomes in terms of morbidity and mortality, as compared with OAR. Unlike elective AAA repair, survival rates between EVAR and OAR do not converge in long term follow up for patients who survived the index hospitalisation.