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Comment & Response
January 2017

In-Hospital Mortality After Elective Abdominal Aortic Aneurysm Repair

Author Affiliations
  • 1School of Medicine, Imperial College London, London, England
JAMA Surg. 2017;152(1):114. doi:10.1001/jamasurg.2016.4198

To the Editor We would like to thank Hicks et al1 for their study analyzing the factors associated with in-hospital mortality after elective abdominal aortic aneurysm (AAA) repair. In their study, they report a lower risk of in-hospital mortality associated with endovascular AAA repair (EVAR) compared with open AAA repair (OAR).

However, we would like to urge caution regarding the generalizability of this finding. It is well established that EVAR confers lower short-term mortality, but there is still a paucity of data supporting its long-term benefits. In fact, several studies have demonstrated that EVAR does not confer any additional long-term benefit over OAR owing to the possible need for reintervention, the persistent risk of AAA rupture, and the high morbidity of accompanying complications such as endoleaks.2 Accordingly, the study by Hicks et al1 was limited to in-hospital mortality as the sole end point and did not perform a further evaluation of perioperative or postoperative complications or long-term survival. This bias is compounded by the large proportion of institutions meeting the Leapfrog criteria, which correlate mortality with the surrogate measure of hospital volume. The shortcomings of this approach have been verified elsewhere,3 but, specifically, it is a better reflection of hospital structural attributes than quality of care and does not account for long-term or postoperative morbidity. Hence, to conclude from this singular analysis of in-hospital mortality that patients would have a better outcome after EVAR than after OAR would be to overstate the case for the benefit of EVAR.

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