title: Comparative effectiveness of endovascular versus open repair of ruptured abdominal aortic aneurysm in the Medicare population.
abstract: OBJECTIVE
  Endovascular aortic repair (EVAR) for abdominal aortic aneurysm (AAA) is increasingly used for emergent treatment of ruptured AAA (rAAA). We sought to compare the perioperative and long-term mortality, procedure-related complications, and rates of reintervention of EVAR vs open aortic repair of rAAA in Medicare beneficiaries.
  
  
  METHODS
  We examined perioperative and long-term mortality and complications after EVAR or open aortic repair performed for rAAA in all traditional Medicare beneficiaries discharged from a United States hospital from 2001 to 2008. Patients were matched by propensity score on baseline demographics, coexisting conditions, admission source, and hospital volume of rAAA repair. Sensitivity analyses were performed to evaluate the effect of bias that might have resulted from unmeasured confounders.
  
  
  RESULTS
  Of 10,998 patients with repaired rAAA, 1126 underwent EVAR and 9872 underwent open repair. Propensity score matching yielded 1099 patient pairs. The average age was 78 years, and 72.4% were male. Perioperative mortality was 33.8% for EVAR and 47.7% for open repair (P < .001), and this difference persisted for >4 years. At 36 months, EVAR patients had higher rates of AAA-related reinterventions than open repair patients (endovascular reintervention, 10.9% vs 1.5%; P < .001), whereas open patients had more laparotomy-related complications (incisional hernia repair, 1.8% vs 6.2%; P < .001; all surgical complications, 4.4% vs 9.1%; P < .001). Use of EVAR for rAAA increased from 6% of cases in 2001 to 31% in 2008, whereas during the same interval, overall 30-day mortality for admission for rAAA, regardless of treatment, decreased from 55.8% to 50.9%.
  
  
  CONCLUSIONS
  EVAR for rAAA is associated with lower perioperative and long-term mortality in Medicare beneficiaries. Increasing adoption of EVAR for rAAA is associated with an overall decrease in mortality of patients hospitalized for rAAA during the last decade.
authors.affiliation: Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Mass.
authors.forename: Samuel T
authors.initials: ST
authors.lastname: Edwards
authors.affiliation: Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Mass.
authors.forename: Marc L
authors.initials: ML
authors.lastname: Schermerhorn
authors.affiliation: Department of Health Care Policy, Harvard Medical School, Boston, Mass.
authors.forename: A James
authors.initials: AJ
authors.lastname: O'Malley
authors.affiliation: Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Mass.
authors.forename: Rodney P
authors.initials: RP
authors.lastname: Bensley
authors.affiliation: Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Mass; Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
authors.forename: Rob
authors.initials: R
authors.lastname: Hurks
authors.affiliation: Centers for Medicare and Medicaid Services, Baltimore, Md.
authors.forename: Philip
authors.initials: P
authors.lastname: Cotterill
authors.affiliation: Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Mass; Department of Health Care Policy, Harvard Medical School, Boston, Mass. Electronic address: landon@hcp.med.harvard.edu.
authors.forename: Bruce E
authors.initials: BE
authors.lastname: Landon
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D017544:Aortic Aneurysm, Abdominal / Q000401:mortality / Q000601:surgery*; D001019:Aortic Rupture / Q000191:economics / Q000401:mortality / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000401:mortality; D016009:Chi-Square Distribution; D018572:Disease-Free Survival; D057510:Endovascular Procedures / Q000009:adverse effects / Q000401:mortality; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D007902:Length of Stay; D008297:Male; D006278:Medicare; D011183:Postoperative Complications / Q000401:mortality / Q000601:surgery; D057216:Propensity Score; D012086:Reoperation; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States