Patients with a ruptured abdominal aortic aneurysm (rAAA)– a very serious life-threatening illness that occurs more often in elderly men– have better outcomes in the United States than in England, according to a new study published in the Lancet.
Researchers at the University of London compared hospital data from 11,799 rAAA patients in England with 23,838 rAAA patients in the U.S. They found that U.S. patients were more likely than English patients to have a procedure to repair the rAAA and to survive their hospital stay.
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Endovascular repair of AAA (abdominal aortic aneurysm) gained enthusiastic acceptance after initial results from three trials (EVAR 1, DREAM, and OVER) found an early survival advantage for endovascular repair compared to open repair. Some of the enthusiasm waned, however, after long-term results from the first two trials found no difference in survival between the groups after the first two years. Now the results of the third trial, the Open versus Endovascular Repair (OVER) Veterans Affairs Cooperative Study Group, have been published in the New England Journal of Medicine. and these confirm the pattern found in the other trials.
The trial randomized 881 patients with asymptomatic AAA who were eligible for either approach. Although in the early years of the trial endovascular repair was superior to open repair, after a mean followup of 5.2 years there were no significant differences in mortality between the two groups, with the same number of deaths (146) deaths occurring in each. Here are the hazard ratios for endovascular repair:
- at 5.2 years: 0.97, CI 0.77 – 1.22, p=0.81
- at 3 years: 0.72, CI 0.51 – 1.00; p=0.05
- at 2 years: 0.63, CI 0.40 – 0.98, p=0.04
Summarizing their findings, the OVER investigators wrote that the two procedures “resulted in similar long-term survival. The perioperative survival advantage with endovascular repair was sustained for several years, but rupture after repair remained a concern. Endovascular repair led to increased long-term survival among younger patients but not among older patients, for whom a greater benefit from the endovascular approach had been expected.”
In an accompanying editorial, Joshua Beckman places OVER within the context of EVAR 1 and DREAM, and points out that “the results of these three clinical trials” have been “incredibly consistent.” All three trials found “an upfront reduction in mortality with catch-up later.” With no significant differences in mortality between the procedures, “patients can weigh the value of open repair, a major operation with greater upfront morbidity and mortality, against that of endovascular repair, with its lower early-event rate but the need for indefinite radiologic surveillance.”
A 2007 Medicare initiative to increase AAA (abdominal aortic aneurysm) screening in appropriate patients failed to prevent AAA rupture or reduce all-cause mortality, according to a new study published in Archives of Internal Medicine. The larger implications of the study are unclear, but two accompanying papers, an invited commentary and a perspective, emphasize the darker side of AAA screening.
Jacqueline Baras Shreibati and colleagues examined the effect of the 2007 Screening Abdominal Aortic Aneurysms Very Efficiently (SAAAVE) Act which provided Medicare coverage for a one-time ultrasound screening for new Medicare patients who were men and who had a history of smoking or women with a family history of AAA. The SAAAVE Act was based on 2005 US Preventive Services Task Force recommendations.
Using Medicare data from 2004 to 2008, the investigators found a modest increase in AAA screening among eligible 65-year-old Medicare men during the study period, from 7.6% in 2004 to 9.6% in 2008. The SAAAVE Act resulted in no significant differences in the rates of AAA repair, AAA rupture, or all-cause mortality, they concluded.
In an invited commentary, Russell Harris, Stacey Sheridan, and Linda Kinsinger write that the evidence about AAA screening has changed since the 2005 USPSTF recommendations. In the past 10-15 years, they write, mortality from ruptured AAA has been cut nearly in half. AAA screening, they maintain, has had little to do with this change; rather, the change is more likely due to long term trends in the reduction of smoking prevalence and the incidence of MI.
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