Open Versus Endovascular Abdominal Aortic Aneurysm Repair in Standard Surgical-Risk Patients Using a Medicare-Matched Registry.

OBJECTIVES: Open surgical repair (OSR) offers the most durable option for abdominal aortic aneurysm (AAA) repair, yet over 80% of repairs in the US are performed using endovascular repair (EVAR). While EVAR suits high-risk patients, both approaches are viable for standard-risk patients, with the choice often based on operator experience and patient anatomy and preference. This study investigates which technique offers better long-term outcomes in standard-risk patients. METHODS: The Medicare-matched VISION database was queried from 2011 to 2019 for standard-risk patients undergoing OSR or EVAR. Patients with high surgical risk features were excluded: age>70, BMI>35, GFR<30, moderate-severe CHF, recent MI, positive stress test, home oxygen, dialysis-dependent, and patients unfit for OSR based on surgeon's judgement. Patients presenting with rupture or with prior aneurysm repair were also excluded. Propensity score matching was used to match baseline characteristics (26 variables) in both groups. Cox regression analyzed mortality, aneurysm-related reintervention, and rupture up to 7 years. RESULTS: Before matching, our study had 7,409 standard-risk patients EVAR 5,933 (80.1%); OSR 1,476 (19.9%). PSM produced two well balanced cohorts of 1,017 pairs. There was no significant difference in 7-year mortality HR=1.08, (0.85-1.38), p=0.511. However, EVAR was associated with higher risk of reintervention at 7 years compared to OSR 20.8% vs 12.4%; HR=1.56, (1.17-2.07), p=0.002. Furthermore, the hazard of rupture was almost 4-folds higher with EVAR 3.2% vs 0.4%; HR=3.87, p=0.018. CONCLUSIONS: In the current era where EVAR is the predominant choice even in low surgical risk patients, reasons to undergo OSR are limited. However, our study demonstrates superior durability of OSR in standard-risk patients with significantly lower rates of reintervention and rupture up to seven years. Our findings provide a strong rationale for performing OSR in physiologically fit patients.