(PC002) Real-World Outcomes of Open Surgical Repair Versus Endovascular Aortic Repair in Ruptured Abdominal Aortic Aneurysms: Does Neck Anatomy Make a Difference?

Objectives: Several studies have demonstrated superior outcomes with Endovascular Aortic Repair (EVAR) compared to open surgical repair (OSR) in patients with infrarenal ruptured abdominal aortic aneurysms (rAAA). However, in emergent settings, the suitability of the aortic neck for EVAR and adherence to IFUs are often not met in a significant portion of patients. We aimed to compare EVAR and OSR in patients with rAAA using a recent national database, considering favorable neck (FN) versus hostile neck (HN) anatomy.

Methods: We analyzed VQI data for rAAA (2018–2024). The study included two analyses: first, a comparison between OSR and EVAR; second, a comparison among three cohorts: OSR, EVAR with FN (EVAR-FN), and EVAR with HN (EVAR-HN). HN was defined as neck length < 15 mm, neck diameter >30 mm, or infrarenal angle >60°. The primary outcomes were 30-day and one-year mortality. Secondary outcomes included postoperative complications, ICU stay >3 days, RBC transfusion >4 units, and postoperative reintervention. Logistic and Cox regressions were used for the analysis.

Results: A total of 4,578 rAAA repairs were performed (EVAR=3,275, 71.5%). Among EVARs, 2,452 (74.9%) had HN. The 30-day mortality was 35.5% for OSR and 21.5% for EVAR (P <.001). The one-year mortality was 42.5% for OSR, 31.7% for all EVARs, 26.1% for EVAR-FN, and 33.5% for EVAR-HN (Figure I). After adjusting for confounders, EVAR was associated with reduced 30-day and one-year mortality (aOR=0.66, 95% CI=0.52–0.84, P=0.001; and aHR=0.79, 95% CI=0.67–0.93, P=0.005). EVAR was also associated with reduced risk of postoperative complications (Table I). When stratified by neck anatomy, EVAR-FN was associated with reduced 30-day (aOR=0.46, 95%CI=0.33-0.65; P<.001) and one-year mortality (aHR=0.66, 95%CI=0.53-0.82; P<.001) compared to OSR. However, EVAR-HN was associated with reduced 30-day (aOR=0.74, 95%CI=0.58-0.94; P=0.013) but not one-year mortality (aHR=0.84, 95%CI=0.71-1.00; P=0.052) compared to OSR. Additionally, EVAR-HN was associated with increased risk of 30-day and one-year mortality compared to EVAR-FN (Table I).

Conclusions: The majority of rAAAs are treated today with EVAR with 75% of these patients having HN. EVAR was associated with reduced postoperative mortality and complication compared to OSR regardless of neck anatomy. However, EVAR maintained one-year survival superiority over OSR only in patients with FN anatomy. While EVAR-HN had similar one-year mortality to OSR, it remains the preferred option due to its better perioperative outcomes and lower 30-day mortality. Further studies with longer follow-up are needed to evaluate reintervention, rupture and aneurysm-related mortality especially in patients with HN anatomy.