Age Related Trends and Long Term Survival in Elective Abdominal Aortic Aneurysms: A Comparison of Endovascular versus Open Repair.

Abstract

Long term survival after endovascular aortic repair (EVAR) vs. open surgical repair (OSR) remains debated. However, EVAR is increasingly used across all ages. This study aimed to compare trends in elective abdominal aortic aneurysm (eAAA) repairs over the last decade and the long term survival by age and surgical technique. This retrospective, multicentre cohort study analysed eAAA interventions in Catalonia (2010 - 2022) using an administrative database. Age trends and EVAR/OSR proportions were examined across three age groups (< 70, 70 - 79, and ≥ 80 years). Survival rates were compared using Cox regression models and restricted mean survival times. Centres were classified as compliant or non-compliant based on European Society for Vascular Surgery 2024 guideline criteria (≥ 15 OSRs, ≥ 15 EVARs, and ≥ 30 AAAs/year). Cubic spline curves were estimated by Cox models as a function of age, with sensitivity analysis for compliant and non-compliant hospitals. Among 5 085 eAAA repairs (70.7% EVAR), 1 638 patients were aged < 70 years, 2 306 were aged 70 - 79 years, and 1 141 were aged ≥ 80 years. Mean age increased by 1.5 months annually (correlation coefficient 0.13; p < .001). EVAR use increased across all age groups, with a higher odds ratio (OR) for EVAR compared with OSR: OR 1.11 (95% confidence interval [CI] 1.08 - 1.14; p < .001) for < 70 years; OR 1.12 (95% CI 1.09 - 1.15; p < .001) for 70 - 79 years; and OR 1.35 (95% CI 1.25 - 1.46; p < .001) for ≥ 80 years. Mean follow up was 5.04 years (95% CI 4.99 - 5.09 years). OSR was associated with better survival in the 70 - 79 age group (hazard ratio [HR] 1.21, 95% CI 1.05 - 1.40). No statistically significant differences were found in the < 70 years (HR 1.14, 95% CI 0.94 - 1.39) and ≥ 80 years (HR 0.88, 95% CI 0.68 - 1.14) age groups. Cubic spline curves showed better survival with OSR for patients aged < 75 years treated at compliant centres. Use of OSR has declined over the last decade across all age groups. Nevertheless, OSR may enhance patient survival compared with EVAR, particularly for patients aged < 75 years in compliant centres.