What’s the Best Approach for Elective Abdominal Aortic Aneurysm Repair?

Harry is a 68-year-old man who was first diagnosed with an abdominal aortic aneurysm (AAA) 8 years ago. Since diagnosis, he has undergone surveillance with computed tomography scans. His most recent scan showed an aneurysm diameter of 6.5 cm. Harry’s surgeon informed him that it was time to consider surgical repair. What’s the best approach to surgical treatment for Harry? Do long-term outcomes differ between endovascular and open surgical repair?

To prevent progression to rupture, guidelines recommend elective repair of AAAs when aneurysm diameter is >6 cm in men. These repairs can be performed endovascularly or via an open surgical procedure. Randomized trials have shown that endovascular repair results in lower perioperative mortality than open repair. However, in observational studies, endovascular repair is associated with excess late morbidity.

In a follow-up study recently published in NEJM, Lederle et al. reported outcomes after an average of 9 years in patients randomized to elective endovascular or open repair. Consistent with previous studies, the results showed that endovascular repair was associated with lower short-term mortality than open repair, but a significantly higher proportion of patients originally randomized to endovascular repair required a secondary procedure. For Harry, these results suggest that although endovascular repair is associated with lower perioperative mortality, open repair may be better in the long run.

 The following NEJM Journal Watch summary explains the study and results in more detail:

Allan S. Brett, MD reviewing Lederle FA et al. N Engl J Med 2019 May 30

In a previously published, randomized U.S. trial of elective repair of abdominal aortic aneurysm (AAA) that involved nearly 900 patients, 30-day postoperative mortality was lower with endovascular repair than with open repair (0.5% vs. 3.0%). After average follow-up of 5 years, mortality was identical — 33% — in the two groups (NEJM JW Gen Med Jan 1 2010 and JAMA 2009; 302:1535; NEJM JW Gen Med Jan 1 2013 and N Engl J Med2012; 367:1988).

Now, the researchers report outcomes at an average follow-up of 9 years. Overall mortality (≈70%) and AAA-related mortality (≈3%) were similar in the two groups. The proportion of patients who underwent a secondary procedure was significantly higher in the endovascular group than in the open-surgery group (27% vs. 20%); the most common secondary procedures were additional endovascular interventions in the endovascular group and incisional hernia repairs in the open-surgery group.

Comment: These long-term results are consistent with those of other randomized and observational studies of elective AAA repair. In patients whose anatomy makes them suitable candidates for either procedure, there are tradeoffs: Endovascular repair is associated with lower perioperative mortality, but open repair is associated with a somewhat lower rate of secondary operative procedures during the years after the procedure. Note, however, that these findings are not necessarily generalizable to women: Nearly all patients in this study (and in the other large randomized trials in which endovascular and open repair were compared) were men.

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Angela is a 2018-2019 NEJM editorial fellow. She is an endocrine fellow who trained at Flinders Medical Centre and the Royal Adelaide Hospital. Angela recieved her medical degree from the University of Adelaide, and masters of public health from the University of Sydney. Her clinical and research interests are in the areas of glucocorticoid and cardiovascular endocrinology and diabetes medicine.