International Clinical Practice Variations in Abdominal Aortic Aneurysm Treatment among Patients under 65 Years of Age: a Report from the International Consortium of Vascular Registries.

Abstract

Societal guidelines recommend risk assessment before elective abdominal aortic aneurysm (AAA) treatment, including consideration of age. Long term durability concerns for endovascular aneurysm repair (EVAR) suggest that age should influence the choice between open aortic repair (OAR) and EVAR. This study aimed to identify international variability in treatment strategies for AAA patients aged < 65 years. OAR and EVAR registry data for intact AAAs from 2014 to 2019 were collected from 11 countries (Australia, USA, Denmark, Hungary, Finland, Iceland, Switzerland, New Zealand, Norway, Sweden, and UK) via the International Consortium of Vascular Registries. Variations in treatment modality, comorbidities, AAA diameter, and peri-operative death were assessed. Of 94 833 patients, 12 682 (13.4%) were aged < 65 years, with statistically significant international variation (range, 8.6% [Sweden, UK] - 25.6% [Hungary], p < .001). EVAR was performed in 59.6% of patients aged < 65 years, with considerable variation across countries (range, 24.9% [Denmark] - 74.0% [USA]). The use of EVAR in general is strongly correlated with its use among patients aged < 65 years (correlation coefficient = 0.88, p < .001). One third of the patients were treated below guideline recommended diameter thresholds: 36.5% of men and 29.3% of women. The likelihood of EVAR increased with age, with variations most pronounced among the youngest patients. Compared with patients who underwent EVAR, those who underwent OAR had statistically significantly larger AAAs (5.9 vs. 5.6 cm, p < .001) and a higher peri-operative mortality rate (1.4 vs. 0.3%, p < .001). Despite similar AAA guidelines from international vascular societies, substantial variability exists in AAA management for patients aged < 65 years, particularly regarding treatment modality, diameter thresholds, and outcomes. Closer evaluation of international practice patterns and gaps in guideline adherence is needed.