Chinsakchai Khamin, Thorthititum Duangruthai, Hongku Kiattisak, Wongwanit Chumpol, Tongsai Sasima, Sermsathanasawadi Nuttawut, Hahtapornsawan Suteekhanit, Puangpunngam Nattawut, Prapassaro Tossapol, Pruekprasert Kanin, Chaisongrit Tiwa, Verhoeven Eric, Ruangsetakit Chanean
Faculty of Medicine Siriraj Hospital, Division of Vascular Surgery, Department of Surgery, Mahidol University, Bangkok, Thailand.
Faculty of Medicine Siriraj Hospital, Research Department, Mahidol University, Bangkok, Thailand.
Ann Vasc Surg. 2025 Mar;112:363-372. doi: 10.1016/j.avsg.2024.12.052. Epub 2024 Dec 26.
Endovascular aneurysm repair (EVAR) has become increasingly prevalent for treating asymptomatic abdominal aortic aneurysms (AAAs). This study compares the early and late outcomes between EVAR and open aneurysm repair (OAR) in asymptomatic AAA patients.
A retrospective observational cohort study was conducted involving 564 patients (445 EVAR and 119 OAR) who underwent AAA repair from January 2010 to January 2022. Primary outcomes included 30-day and in-hospital mortality. Secondary outcomes encompassed operative details, hospital stay, complications, and long-term survival. A post-hoc noninferiority analysis for 30-day mortality was performed with a noninferiority margin of 1%.
EVAR patients were older (75.6 ± 7.7 vs. 68.7 ± 9.5 years, P < 0.001) and more often deemed unfit for open repair (53.0% vs. 10.1%, P < 0.001). EVAR demonstrated advantages in operative time (149.5 ± 70.8 vs. 303.5 ± 115.7 minutes, P < 0.001), blood loss (median 200 vs. 1,500 mL, P < 0.001), and hospital stay (median 5 vs. 9 days, P < 0.001). Thirty-day mortality was 0.9% for EVAR and 3.4% for OAR. Post-hoc noninferiority analysis suggested EVAR was noninferior to OAR for 30-day mortality (difference -2.47%, 95% confidence interval: -0.5% to 5.4%, P = 0.005). EVAR had significantly fewer early reinterventions (1.3% vs. 8.4%, P < 0.001). Detailed complication analysis revealed that EVAR had significantly fewer early laparotomy-related complications (0.2% vs. 5.0%, P < 0.001) but more late aneurysm-related complications (16.9% vs. 5.0%, P = 0.002). Conversely, OAR had more late laparotomy-related complications (8.4% vs. 0.2%, P < 0.0001). The combined rate of late complications was not significantly different between groups (17.1% vs. 13.4%, P = 0.314). The EVAR group exhibited lower 5-year survival, likely due to the higher proportion of elderly and unfit patients.
The post-hoc noninferiority analysis suggests that EVAR is noninferior to OAR in terms of 30-day mortality for asymptomatic AAA patients. EVAR demonstrated perioperative benefits and fewer early complications, while long-term complication profiles differed between procedures. These findings support EVAR as a valuable option, particularly for higher-risk patients, while highlighting the need for procedure-specific long-term surveillance. Future prospective studies are needed to confirm these post-hoc findings.
血管内动脉瘤修复术（EVAR）在治疗无症状腹主动脉瘤（AAA）方面日益普遍。本研究比较了无症状AAA患者接受EVAR和开放性动脉瘤修复术（OAR）的早期和晚期结果。
进行了一项回顾性观察队列研究，纳入了2010年1月至2022年1月期间接受AAA修复术的564例患者（445例接受EVAR，119例接受OAR）。主要结局包括30天死亡率和住院死亡率。次要结局包括手术细节、住院时间、并发症和长期生存率。对30天死亡率进行了事后非劣效性分析，非劣效界值为1%。
EVAR组患者年龄更大（75.6±7.7岁 vs. 68.7±9.5岁，P<0.001），且更常被认为不适合开放性修复（53.0% vs. 10.1%，P<0.001）。EVAR在手术时间（149.5±70.8分钟 vs. 303.5±115.7分钟，P<−0.001）、失血量（中位数200 vs. 1500 mL，P<0.001）和住院时间（中位数5天 vs. 9天，P<0.001）方面具有优势。EVAR的30天死亡率为0.9%，OAR为3.4%。事后非劣效性分析表明，在30天死亡率方面，EVAR不劣于OAR（差异为−2.47%，95%置信区间：−0.5%至5.4%，P=0.005）。EVAR的早期再次干预显著更少（1.3% vs. 8.4%，P<0.001）。详细的并发症分析显示，EVAR的早期剖腹手术相关并发症显著更少（0.2% vs. 5.0%，P<0.001），但晚期动脉瘤相关并发症更多（16.9% vs. 5.0%，P=0.002）。相反，OAR的晚期剖腹手术相关并发症更多（8.4% vs. 0.2%，P<0.0001）。两组晚期并发症的综合发生率无显著差异（17.1% vs. 13.4%，P=0.314）。EVAR组的5年生存率较低，可能是由于老年和不适合手术的患者比例较高。
事后非劣效性分析表明，对于无症状AAA患者，EVAR在30天死亡率方面不劣于OAR。EVAR显示出围手术期益处和更少的早期并发症，而不同手术的长期并发症情况有所不同。这些发现支持EVAR作为一种有价值的选择，特别是对于高风险患者，同时强调了针对特定手术进行长期监测的必要性。未来需要进行前瞻性研究来证实这些事后分析结果。
