Treatment Options for Abdominal Aortic Aneurysm

Open Surgery vs. Endovascular Aneurysm Repair of Abdominal Aortic Aneurysm

The Joint Council of the American Association of Vascular Surgeons (JCAAVS) notes that patient preference is an important factor in the decision regarding undergoing open repair or EVAR for abdominal aortic aneurysm (AAA). Even though EVAR is increasingly used, it is still not considered superior to open repair in terms of long-term durability. The greatest advantages of EVAR are its lower postoperative morbidity rate, reduced hospital stay, and reduced hospital cost. However, there is still a significant rate of postoperative complications and reintervention as well as a demand for serious commitment to lifelong surveillance. Endovascular aneurysm repair cannot yet be routinely substituted for open AAA repair surgery. It is advantageous for only a select population. In younger patients with good risk profiles, open repair surpasses EVAR for long term success and is recommended. The threat of rupture of an abdominal aortic aneurysm is virtually eliminated (1-2%) following either type of surgery.

Operative mortality rates of open repair are equivalent to those of EVAR but EVAR is associated with fewer cardiac, gastrointestinal, and pulmonary complications in addition to a reported faster recovery time and return to activity. On the other hand, EVAR is associated with complications usually not seen with open AAA surgery (e.g., higher rate of intervention due to endoleaks, device migration, ongoing lifetime surveillance).

Determination of which surgical procedure may be more appropriate for an individual is made by the assessment of several factors, including:

  • Anatomy - EVAR is not an option for AAAs of certain shapes and sizes such as:

    • large aortic neck
    • AAAs that extend to the renal (kidney) level of the aorta
    • significantly twisted or tortuous aorta
    • thrombus (clots) or calcifications at the site where the stent-graft attaches to the wall of the artery

  • Patient's age

  • Presence of other underlying medical conditions
  • Experience of the surgeon and hospital with AAA surgery
  • Probability of surviving open surgery

Performing EVAR on patients with unsuitable anatomy significantly increases the risk of conversion to open repair, complications, or rupture of the AAA.

Clinical trials comparing the long term efficacy and safety of EVAR and open surgery are ongoing. Currently there is no indication that EVAR reduces the risk of rupture which is approximately 1% per year.

The results of two EVAR trials comparing the outcome of open repair vs. EVAR published in 2005 indicated that:

  • While EVAR resulted in a 3% higher aneurysm-related survival, there was no difference between the two procedures regarding general mortality (not directly related to the AAA) or quality of life.
  • EVAR was more expensive
  • There was a higher number of complications than with open surgery
  • There was a higher rate of reintervention following EVAR

To read about the studies published in the journal Lancet in 2005, comparing EVAR to open repair of AAA in greater depth, please click on the following links:

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&listuids=15978925&queryhl=1&itool=pubmed_docsum

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&listuids=15978926&queryhl=1&itool=pubmed_docsum

As surgeons have become more familiar with endovascular repair, the mortality rates associated with this procedure have decreased. In a study published in 2004 in the Journal of Vascular Surgery (Volume 39; pages 10-19), researchers reported that patients who underwent endovascular repair had significantly fewer postoperative complications and a higher survival rate as compared to patients who underwent open repair. The in-hospital mortality rate in this study was 4% for open repair and less than 1% for endovascular repair.

It has been estimated that the overall 5-year survival rate following any surgery for repair of abdominal aortic aneurysm is approximately 60%. Factors most associated with prolonged survival include:

Another factor which the patient must keep in mind before making the decision regarding the type of surgery for repair of their AAA is that endovascular repair is considerably more expensive than open repair even though the hospital stay is approximately 50% shorter. Before making a final decision, patients should check with their health insurance carrier regarding reimbursement for each procedure.