Large Abdominal Aortic Aneurysm Repair More Successful Long Term With Open Procedure

Researchers sought to assess the association of large abdominal aortic aneurysm (AAA) diameter with late outcomes in patients undergoing open and endovascular AAA repair.

Open repair of large abdominal aortic aneurysms (AAAs) should be considered, as endovascular repair of large AAAs is associated with reintervention, ruptures, and mortality. These findings, from a retrospective analysis of Medicare claims, were published in the Journal of Vascular Surgery.

Data from the Vascular Quality Initiative (VQI), linked with Medicare claims were analyzed for this study. All patients (N=21,119) undergoing open or endovascular repair of infrarenal AAAs between 2003 and 2016 were assessed for long-term outcomes. Large AAAs were defined as an AAA diameter >65 mm, medium-sized AAAs as diameter <65 mm and >55 mm for men and >50 for women, and small AAAs as greater than or equal to 55 mm for men and greater than or equal to 50 mm for women.

Patients underwent endovascular (n=19,017) or open (n=2102) repair, and 15.2% were large AAAs. The incidence of large AAAs has been declining over time, from 22.5% in 2003 to 13.5% in 2016. Endovascular repair has been increasing among patients with large AAAs, from 34.9% in 2003 to 90.6% in 2016.

Patients with large AAAs were older (76 vs 75 years; P <.001), fewer were women (16.2% vs 21.7%; P <.001), they were less likely to have a history of coronary artery disease (41.4% vs 43.8%; P =.011) and hypertension (82.6% vs 84.1%; P =.037), and they took fewer preoperative statins (65.3% vs 71.7%; P <.001) or P2Y12 (9.3% vs 12.1%; P <.001) compared with patients with small AAAs, respectively.

Among patients who underwent endovascular repair, at 60 months those who had large AAAs had lower rates of freedom from reintervention (73.9% vs 84.6%; P <.001), freedom from rupture (88.5% vs 93.6%; P <.001), and survival (58.0% vs 66.4%; P <.001) compared with patients who had small- or medium-sized AAAs.

Among patients who underwent open repair, no differences were observed for reintervention, rupture, or survival rates on the basis of AAA diameter.

Survival was increased among patients who underwent an open procedure compared with endovascular procedure for large AAAs (63.7% vs 55.3%) and medium-sized or small AAAs (70.6% vs 67.3%). According to the Vascular Study Group of New England (VSGNE) risk score, the majority of patients with large AAAs (73.6%) had little risk (<5%) for open repair mortality.

These findings may have been biased by the data source and may not be generalizable for the privately insured population in the US or other regions.

These data indicated patients who had large AAAs were associated with poorer clinical outcomes from endovascular repair compared with open surgery. The study authors’ findings are of critical importance as the rates of endovascular repair of large AAAs have been increasing during the past decade.


De Guerre LEVM, Dansey K, Li C, et al. Late outcomes after endovascular and open repair of large abdominal aortic aneurysms. J Vasc Surg. 2021;S0741-5214(21)00326-8. doi: 10.1016/j.jvs.2021.02.024