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Long-Term Survival Of Cardiac High-Risk Patients Undergoing Endovascular Abdominal Aortic Aneurysm Repair Is Similar To Open Surgical Repair

Olaf Schouten¹, Tannie M Lever², Gijs M J Welten¹, Ron T. van Domburg¹, Hence J. Verhagen², Jeroen J. Bax³, Don Poldermans.^1
1Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands; ²UMCU, Utrecht, The Netherlands; ³Leiden University Medical Center, Leiden, The Netherlands.

OBJECTIVES: Despite a reduced incidence of adverse perioperative events endovascular abdominal aortic aneurysm (AAA) repair seems not to be associated with a long-term survival benefit. However, long-term outcome of patients at high cardiac risk is ill defined. Therefore the aim of the current study was to compare long term outcome in patients at high cardiac risk undergoing endovascular or open AAA repair.

METHODS: Consecutive patients undergoing open or endovascular infrarenal AAA repair with > 3 cardiac risk factors (age > 70 years, angina pectoris, myocardial infarction, heart failure, stroke, renal failure, and diabetes mellitus) at two University hospitals between January 2000 and January 2007 were studied. All patients underwent preoperative non-invasive cardiac stress testing. The outcome measure was all-cause mortality, assessed by contacting the civil registry. Multivariate Cox regression analysis was used to evaluate the influence of type of AAA repair on long-term outcome. Propensity scores for type of surgery were included in multivariate analysis.

RESULTS: All 120 high-risk patients (54 endovascular, 66 open) had a history of cardiac disease. The number and type of cardiac risk factors as well as medication use were equal in both groups. Also non-invasive cardiac stress testing results were similar: 55 vs 53%, 30 vs 34%, and 15 vs 13% had no, limited, or extensive stress-induced myocardial ischemia during non-invasive cardiac imaging respectively. The incidence of death during a median follow-up of 2.8 years was similar in endovascular and open treated patients (p=0.72, figure 1). Also after using multivariable analysis, adjusting for cardiac risk factors, cardiac stress test results, medication use, and propensity score there was no significant difference between endovascular and open repair during long-term follow-up (HR 0.83, 95% CI 0.31-2.26). Importantly, in multivariable analysis statin use was independently associated with improved long-term outcome (HR 0.34, 95%CI 0.13-0.91, figure 2).

CONCLUSIONS: Endovascular repair of infrarenal AAA in high cardiac risk patients has a similar long-term outcome compared to open repair. These high cardiac risk patients could benefit from aggressive medical therapy.