Editor's Choice-Trends in Treatment Strategies and Peri-operative Outcomes for Complex Abdominal Aortic Aneurysms: A VASCUNET Report

Objective: This multinational, registry based, observational study within the VASCUNET framework aimed to examine trends in treatment strategies and peri-operative outcomes for intact and ruptured complex abdominal aortic aneurysms (cAAAs) across seven countries. Methods: This study used aggregated data from vascular registries in Australia, Denmark, Finland, New Zealand, Portugal, Sweden, and Switzerland. Patients treated with open repair (OR) and fenestrated or branched endovascular aortic repair (FBEVAR) for intact and ruptured cAAAs between 2018 and 2022 were included. The primary outcome was peri-operative death (30 day or in hospital). Weighted peri-operative mortality rates with 95% confidence intervals (CIs) were calculated, and variations in treatment practices and outcomes were assessed. Results: A total of 3 344 patients treated for intact cAAA and 547 patients treated for ruptured cAAA were included. An overall increase in the use of FBEVAR for intact cAAA was observed, rising from 50% in 2018 to 54% in 2022, with Denmark showing the largest rise from 33% to 71%. The highest FBEVAR rate was seen in Australia at 68% and the lowest in Switzerland at 25%. In contrast, OR was the predominant treatment for ruptured cAAA, accounting for 94% of all procedures without a clear trend. The overall peri-operative mortality rate for intact cAAA decreased from 5.2% (95% CI 3.3 - 7.0%) in 2018 to 2.4% (95% CI 1.3 - 3.5%) in 2022, although the trend was not statistically significant (p = .093). No time trend was observed in the perioperative mortality for ruptured cAAA, with an overall mortality rate of 35.6%. Complication rates, including myocardial infarction, acute kidney failure, and respiratory failure, were more frequent in OR patients. Conclusion: While the use of FBEVAR for elective cAAA repair has increased and mortality rates have shown a declining trend, the treatment of ruptured cAAA continues to predominantly rely on OR, with high perioperative mortality rates. These findings highlight the need for ongoing advances in endovascular technologies for ruptured cAAA repair.