Clinical question How do long-term outcomes compare for open surgery and endovascular aneurysm repair (EVAR)?
Bottom line Although short-term operative mortality is lower with EVAR (number needed to treat [NNT] = 40), this advantage is lost over time, and patients undergoing EVAR have more complications and re-interventions. Long-term costs are also higher with EVAR. (Level of evidence = 1b)
Synopsis Patients 60 years and older with abdominal aortic aneurysms (AAA) at least 5.5 cm in diameter were randomized to receive EVAR or open repair. The patients not medically fit for surgery were enrolled in a separate trial comparing EVAR with watchful waiting. A total of 1,252 patients were enrolled and followed up for 5 to 10 years depending on when they were initially enrolled. Groups were balanced at the start of the study and analysis was by intention to treat. The mean age of participants was 74 years, 90% were male, and the mean AAA diameter was 6.5 cm. Adherence to randomization was good, with all but 36 having an aneurysm repair (12 in the EVAR group and 24 in the open repair group). At 30 days, operative mortality was higher in the open repair group (4.3% vs 1.8%;
P = .02; NNT = 40). However, overall mortality by the end of the follow-up period was the same between groups, and there were more complications (12.6% vs 2.5%;
P < .001; number needed to treat to harm [NNTH] = 10) and reinterventions (5.1% vs 1.7%;
P < .001; NNTH = 29) in the EVAR group. Rupture of the endovascular graft occurred in 25 patients in the EVAR group (4%). The cost of care was higher in the EVAR group as well: $19,700 versus $17,900.
United Kingdom EVAR Trial Investigators. Endovascular versus open repair of abdominal aortic aneurysm. N Engl J Med. 2010;362(20):1863-1871.
Levels of evidence in
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