A 10-Year Retrospective Comparison of Endovascular and Open Aneurysm Repair for Infective Native Abdominal Aortic Aneurysm

Background

This study compared outcomes of endovascular (EVAR) and open aneurysm repair (OAR) in patients with infective native abdominal aortic aneurysms (INAAAs), evaluating perioperative and in-hospital mortality, antibiotic treatment duration, complications, overall survival rates, and reintervention-free times at 10 years.

Methods

A retrospective cohort study of 125 INAAA patients (80 EVAR, 45 OAR) diagnosed between January 2004 and December 2019 was conducted. Patients were categorized as fit or unfit for open surgery based on cardiac, respiratory, and renal status, following the guidelines established in the EVAR-1 and EVAR-2 trials. Primary outcomes included 30-day and in-hospital mortality. Secondary outcomes encompassed early and late complications requiring reintervention, antibiotic treatment duration, 10-year overall survival, 10-year reintervention-free survival, and factors influencing 30-day mortality. Statistical analysis used chi-square, t-tests, and Mann-Whitney U tests. Logistic regression assessed mortality. Kaplan-Meier estimation evaluated survival. Analyses used SPSS version 18.0 (P < 0.05 considered significant)

Results

Males predominated in both OAR (37 of 45, 82.2%) and EVAR (62 of 80, 77.5%) groups (P = 0.693). Mean age was 64.8 ± 9.8 years for OAR and 69.0 ± 12.6 years for EVAR (P = 0.063). The abdominal aorta was the most common aneurysm location, accounting for 91 of 125 (72.8%) cases. Salmonella spp. accounted for 19 of 45 (42.2%) of positive culture cases, and 34 of 125 (27.2%) patients had ruptured aneurysms. The EVAR group had a higher proportion of unfit patients (41 of 80, 51.2%) compared to OAR (10 of 45,22.2%; P = 0.003). Thirty-day mortality rates were 6 of 80 (7.5%) for EVAR and 2 of 45 (4.4%) for OAR; odds ratio (OR) = 1.75 (95% confidence interval (CI): 0.34–9.06), P = 0.508, while in-hospital mortality rates were 7 of 80 (8.8%) and 5 of 45 (11.1%); OR = 0.77 (95% CI: 0.23–2.58), P = 0.668. No significant differences were found in antibiotic treatment duration (median 11 vs. 6 months, P = 0.594), 10-year overall survival rates (62.8% vs. 64.8%, P = 0.90), or reintervention-free time (83.8% vs. 82.2%, P = 0.922), and aneurysm-related death (84.7% vs. 92.9%, P = 0.159). Unfit patient status was an independent predictor of 30-day mortality (adjusted OR, 10.654; 95% CI, 1.041–109.030; P = 0.046).

Conclusions

Our study demonstrates that EVAR and OAR provide comparable outcomes in INAAA management, despite EVAR being performed more frequently in unfit patients. The similar early mortality rates, antibiotic treatment durations, and long-term survival between the 2 approaches support EVAR as a viable alternative to OAR. Importantly, our finding that unfit patient status independently predicts perioperative mortality emphasizes the critical role of patient selection in treatment decisions. These results collectively suggest that EVAR may be particularly beneficial for high-risk INAAA patients unsuitable for OAR, potentially expanding treatment options for this challenging condition.