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A retrospective study of data from the Department of Veteran Affairs (VA) National Surgical Quality Improvement Program (NSQIP) indicates that older or high risk patients with considerable medical comorbidities and abdominal aortic aneurysms could benefit from and should be considered for primary endovascular abdominal aortic aneurysm repair (EVAR). This minimally invasive surgical procedure is designed to protect a patient with an infrarenal abdominal aortic aneurysm against future aneurysm rupture and possible death from rupture. It is associated with early improvements in physical mobility and pain as well as a likelihood for a patient to be discharged to home rather than an institution.

Lead author, Ruth L. Bush, MD, who holds a master’s of public health, is with the department of surgery at Baylor College of Medicine in Houston, and said the study included more than 2,966 high risk patients from 123 VA hospitals who elected to have abdominal aneurysm repair."The 983 patients who underwent EVAR had statistically significantly lower risk-adjusted perioperative mortality rates, lower complication rates, improved survival and shorter lengths of stay compared to patients who had open repair," said Dr. Bush. "Even the highest risk patients had lower mortality and morbidity rates compared to open surgical patients."

"We used NSQIP because it is the largest validated and meticulously maintained U.S. surgical database representing current clinical practice,” said Dr. Bush."It represents routine surgical care that is used for the general population and does not have patient or aneurysm morphologic exclusion criteria that randomized trials contain which also helps us generalize our findings beyond the VA patients. We cross-referenced the NSQIP data with inpatient and outpatient VA files to ensure accuracy of ICD-9 code reporting and to confirm co-morbidities. The NSQUIP includes variability in surgical techniques and skills, even though procedure and device specific variables are not included.”    

Patients who had EVAR had significantly better results than those who had open surgery: Outcomes at 30-days were 3.2 percent vs. 5.3 percent; at one year, mortality was 8.3 percent vs. 11.2 percent, despite the presence of one or more comorbid conditions. Perioperative complications were significantly lower as well (15.5 vs. 28.9 percent).

Dr. Bush added that this study was in dramatic contrast to the prospective randomized EVAR Trial 2 that was done in the United Kingdom. High risk criteria were used evaluate patients was similar in both trials, however in Trial 2 findings suggested patients medially unfit for open repair should not be offered EVAR.

"The 30-day mortality rate was 3.2 percent for EVAR in our study compared to the 9.0 percent in EVAR Trial 2," said Dr. Bush. "Also in Trial 2, fitness for open abdominal aortic aneurysm repair was decided by the evaluating radiologist, surgeon or cardiologist with no specific inclusion or exclusion criteria.”

Criteria use for the United States study include persons ages 60 and older; an American Society of Anesthesiologists classification of 3 or 4, and review of comorbidities including history of cardiac events; respiratory or hepatic disease; cardiac revascularization; renal insufficiency; and low serum albumin.

“Our outcomes show that EVAR is a viable surgical option for many elderly and high risk patients, offering them less pain, more mobility and the possibility of returning home,” added Dr. Bush