Editor's Choice - Comparison of Open Surgery and Endovascular Techniques for Juxtarenal and Complex Neck Aortic Aneurysms: The UK COMPlex AneurySm Study (UK-COMPASS) - Peri-operative and Midterm Outcomes

Srinivasa R Vallabhaneni; Shaneel R Patel; Bruce Campbell; Jonathan R Boyle; Andrew Cook; Alastair Crosher; Sophie M Holder; Michael P Jenkins; David C Ormesher; Anna Rosala-Hallas; Richard J Jackson

doi:10.1016/j.ejvs.2024.02.037

Editor's Choice - Comparison of Open Surgery and Endovascular Techniques for Juxtarenal and Complex Neck Aortic Aneurysms: The UK COMPlex AneurySm Study (UK-COMPASS) - Peri-operative and Midterm Outcomes

Eur J Vasc Endovasc Surg. 2024 Apr;67(4):540-553. doi: 10.1016/j.ejvs.2024.02.037. Epub 2024 Feb 29.

Authors

Affiliations

¹ Liverpool University Hospitals NHS Foundation Trust, Aintree University Hospital, Liverpool, UK; Department of Cardiovascular and Metabolic Medicine, University of Liverpool, Liverpool, UK. Electronic address: fempop@liverpool.ac.uk.
² Liverpool University Hospitals NHS Foundation Trust, Aintree University Hospital, Liverpool, UK; Department of Cardiovascular and Metabolic Medicine, University of Liverpool, Liverpool, UK.
³ Royal Devon University Healthcare Trust, Exeter, UK; University of Exeter Medical School, Exeter, UK.
⁴ Cambridge University Hospitals NHS Trust, Cambridge, UK; Department of Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK.
⁵ University of Southampton, Southampton, UK.
⁶ Liverpool University Hospitals NHS Foundation Trust, Royal Liverpool University Hospital, Liverpool, UK.
⁷ Imperial College Healthcare NHS Trust, St Mary's Hospital, London, UK.
⁸ East Lancashire Hospitals NHS Trust, Royal Blackburn Teaching Hospital, Blackburn, UK.
⁹ Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK.

PMID: 38428672
DOI: 10.1016/j.ejvs.2024.02.037

Abstract

Objective: Treatment of juxtarenal and complex neck abdominal aortic aneurysms (AAAs) is now commonly by endovascular rather than open surgical repair (OSR). Published comparisons show poor validity and scientific precision. UK-COMPASS is a comparative cohort study of endovascular treatments vs. OSR for patients with an AAA unsuitable for standard on label endovascular aneurysm repair (EVAR).

Methods: All procedures for AAA in England (November 2017 to October 2019) were identified, AAA anatomy assessed in a Corelab, peri-operative risk scores determined, and propensity scoring used to identify patients suitable for either endovascular treatment or OSR. Patients were stratified by aneurysm neck length (0 - 4 mm, 5 - 9 mm, or ≥ 10 mm) and operative risk; the highest quartile was considered high risk and the remainder standard risk. Death was the primary outcome measure. Endovascular treatments included fenestrated EVAR (FEVAR) and off label standard EVAR (± adjuncts).

Results: Among 8 994 patients, 2 757 had AAAs that were juxtarenal, short neck, or complex neck in morphology. Propensity score stratification and adjustment method comparisons included 1 916 patients. Widespread off label use of standard EVAR devices was noted (35.6% of patients). The adjusted peri-operative mortality rate was 2.9%, lower for EVAR (1.2%; p = .001) and FEVAR (2.2%; p = .001) than OSR (4.5%). In standard risk patients with a 0 - 4 mm neck, the mortality rate was 7.4% following OSR and 2.3% following FEVAR. Differences were smaller for patients with a neck length ≥ 5 mm: 2.1% OSR vs. 1.0% FEVAR. At 3.5 years of follow up, the overall mortality rate was 20.7% in the whole study population, higher following FEVAR (27.6%) and EVAR (25.2%) than after OSR (14.2%). However, in the 0 - 4 mm neck subgroup, overall survival remained equivalent. The aneurysm related mortality rate was equivalent between treatments, but re-intervention was more common after EVAR and FEVAR than OSR.

Conclusion: FEVAR proves notably safer than OSR in the peri-operative period for juxtarenal aneurysms (0 - 4 mm neck length), with comparable midterm survival. For patients with short neck (5 - 9 mm) and complex neck (≥ 10 mm) AAAs, overall survival was worse in endovascularly treated patients compared with OSR despite relative peri-operative safety. This warrants further research and a re-appraisal of the current clinical application of endovascular strategies, particularly in patients with poor general survival outlook owing to comorbidity and age.

Keywords: Cohort comparison study; Complex abdominal aortic aneurysm; Fenestrated endovascular aneurysm repair; Juxtarenal aortic aneurysm; Off label use.