A substantial early survival advantage that gradually decreased over time was the result of endovascular repair, as compared with open repair, of abdominal aortic aneurysm in 39,966 matched pairs of Medicare beneficiaries. The rate of late rupture was significantly higher following endovascular repair than after open repair among the patients, who were assessed for perioperative and long-term survival reinterventions, and complications. The study also found:

• Overall perioperative mortality was 1.6% with endovascular repair versus 5.2% with open repair.

• From 2001 through 2008, perioperative mortality decreased by 0.8 percentage points among patients who underwent endovascular repair and by 0.6 percentage points for open repair.

• Through the first 3 years of follow-up, the rate of survival was significantly higher after endovascular repair than after open repair.

• Aneurysm rupture occurred in 5.4% of patients after endovascular repair versus 1.4% of patients after open repair through 8 years follow-up.

Citation: Schermerhorn ML, Buck DB, O’Malley, AJ, et al. Long-term outcomes of abdominal aortic aneurysm in the Medicare population. N Engl J Med 2015; 373:328-338.

Commentary: Endovascular repair of aortic aneurysms currently accounts for over three-quarters of all aneurysm repairs. It has been clear since introduction of the procedure that endovascular repair is an easier procedure than an open repair, with reduced perioperative mortality, less perioperative complications and an easier post-operative course for patients. The question that has been raised is whether these short-term benefits occur at the cost of an increase in the rate of long-term rupture. This study shows that the safety of both procedures has improved over time and that endovascular repair is clearly safer over the first 3 years after the procedure due to a lower perioperative risk. Over a longer period of time, the endovascular procedure has a higher rate of complications including late rupture. —Neil Skolnik, MD