Inferior long-term survival with endovascular versus open repair of abdominal aortic aneurysm
medwireNews: Results from the EVAR trial 1 suggest that patients have poorer survival beyond 8 years after endovascular aneurysm repair (EVAR) compared with open repair, despite an early survival benefit.
“[This] needs to be addressed by lifelong surveillance of EVAR and re-intervention if necessary”, write Roger Greenhalgh (Imperial College London, UK) and colleagues in The Lancet.
The researchers found a significant survival benefit with EVAR versus open repair at 0–6 months after randomisation (adjusted hazard ratio [HR]=0.61 for total mortality and 0.47 for aneurysm-related mortality), but EVAR had higher mortality beyond 8 years of follow-up (adjusted HR=1.25 for total mortality and 5.82 for aneurysm-related mortality).
Thus, over a mean of 12.7 years of follow-up (maximum 15.8 years), no overall difference in survival was found between the EVAR and open-repair groups (9.3 vs 8.9 deaths per 100 person–years).
“The increased aneurysm-related mortality beyond 8 years was mainly attributable to secondary aneurysm sac rupture post-EVAR”, explain Isabelle Van Herzeele and Frank Vermassen (Ghent University Hospital, Belgium) in an accompanying commentary.
Aneurysm re-intervention rates were 4.1 per 100 person–years in the EVAR group, and 1.7 per 100 person–years in the open-repair group. The majority of re-interventions took place within 4 years of the initial treatment.
Beyond 8 years of follow-up, death caused by secondary aneurysm rupture occurred in 13 patients (7%) in the EVAR group, versus two (1%) in the open repair group.
In the EVAR trial 1, data were analysed from 1252 patients with abdominal aortic aneurysm who were randomly assigned to receive EVAR or open repair between 1999 and 2004. The overall mean age of patients was 74 years.
Van Herzeele and Vermassen note that “[i]n this trial, patients were treated more than 12 years ago and, fortunately, medical and endovascular management have since progressed”.
They add that “some complications that are now known to cause aneurysm rupture were not treated”.
Despite the limitations of the investigation, the study authors conclude that long-term surveillance after EVAR should be included in clinical practice guidelines, and that the long-term results of the EVAR 1 study can act as a benchmark for future investigations.
Van Herzeele and Vermassen note the worldwide popularity of EVAR, and conclude that the study findings “might have implications for case selection, patients’ treatment choices, and continuous surveillance after EVAR”.
medwireNews is an independent medical news service provided by Springer Healthcare Limited. © Springer Healthcare Ltd; 2016