Why the study?
Substantial changes in elective AAA repair have occurred, including EVAR introduction and intensified cardiovascular risk management, but it remained unclear whether these changes improved longevity.
Does the shift to EVAR-first strategy and intensified cardiovascular risk management improve long-term relative survival in patients undergoing elective AAA repair?
Does the shift to EVAR-first strategy and intensified cardiovascular risk management improve long-term relative survival in patients undergoing elective AAA repair?
Despite shifts toward EVAR and intensified risk management, long-term relative survival after elective AAA repair remains compromised, particularly in women, driven largely by cardiovascular mortality.
Short-term mortality gains from EVAR and risk management leave long-term AAA survival unchanged; leaves open need for targeted secondary prevention trials.
OBJECTIVE: To evaluate the impact of changes in elective Abdominal Aortic Aneurysm (AAA) management on life-expectancy of AAA patients. BACKGROUND: Over the past decades AAA repair underwent substantial changes, that is, the introduction of EVAR and implementation of intensified cardiovascular risk management. The question rises to what extent these changes improved longevity of AAA patients. METHODS: National evaluation including all 12.907 (82.7% male) patients who underwent elective AAA repair between 2001 and 2015 in Sweden. The impact of changes in AAA management was established by a time-resolved analysis based on 3 timeframes: open repair dominated period (2001-2004, n = 2483), transition period (2005-2011, n = 6230), and EVAR-first strategy period (2012-2015, n = 4194). Relative survival was used to quantify AAA-associated mortality, and to adjust for changes in life-expectancy. RESULTS: Relative survival of electively treated AAA patients was stable and persistently compromised [4-year relative survival and 95% confidence interval: 0.87 (0.85-0.89), 0.87 (0.86-0.88), 0.89 (0.86-0.91) for the 3 periods, respectively]. Particularly alarming is the severely compromised survival of female patients (4-year relative survival females 0.78, 0.80, 0.70 vs males 0.89, 0.89, 0.91, respectively). Cardiovascular mortality remained the main cause of death (51.0%, 47.2%, 47.9%) and the proportion cardiovascular disease over non-cardiovascular disease death was stable over time. CONCLUSIONS: Changes in elective AAA management reduced short-term mortality, but failed to improve the profound long-term survival disadvantage of AAA patients. The persistent high (cardiovascular) mortality calls for further intensification of cardiovascular risk management, and a critical appraisal of the basis for the excess mortality of AAA patients.
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Bulder et al. (2020) studied this question.
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