Long-Term Prognosis After Elective Abdominal Aortic Aneurysm Repair Is Poor in Women and Men

The Challenges Remain

Ruth M. A. Bulder, Bsc; Mareia Talvitie, MD; Esther Bastiaannet, PhD; Jaap F. Hamming, MD, PhD; Rebecka Hultgren, MD, PhD; Jan H. N. Lindeman, MD, PhD


Annals of Surgery. 2020;272(5):773-778. 

In This Article

Abstract and Introduction


Objective: To evaluate the impact of changes in elective Abdominal Aortic Aneurysm (AAA) management on life-expectancy of AAA patients.

Background: Over the past decades AAA repair underwent substantial changes, that is, the introduction of EVAR and implementation of intensified cardiovascular risk management. The question rises to what extent these changes improved longevity of AAA patients.

Methods: National evaluation including all 12.907 (82.7% male) patients who underwent elective AAA repair between 2001 and 2015 in Sweden. The impact of changes in AAA management was established by a time-resolved analysis based on 3 timeframes: open repair dominated period (2001–2004, n = 2483), transition period (2005–2011, n = 6230), and EVAR-first strategy period (2012–2015, n = 4194). Relative survival was used to quantify AAA-associated mortality, and to adjust for changes in life-expectancy.

Results: Relative survival of electively treated AAA patients was stable and persistently compromised [4-year relative survival and 95% confidence interval: 0.87 (0.85–0.89), 0.87 (0.86–0.88), 0.89 (0.86–0.91) for the 3 periods, respectively]. Particularly alarming is the severely compromised survival of female patients (4-year relative survival females 0.78, 0.80, 0.70 vs males 0.89, 0.89, 0.91, respectively). Cardiovascular mortality remained the main cause of death (51.0%, 47.2%, 47.9%) and the proportion cardiovascular disease over non-cardiovascular disease death was stable over time.

Conclusions: Changes in elective AAA management reduced short-term mortality, but failed to improve the profound long-term survival disadvantage of AAA patients. The persistent high (cardiovascular) mortality calls for further intensification of cardiovascular risk management, and a critical appraisal of the basis for the excess mortality of AAA patients.


Although the impaired longevity of abdominal aortic aneurysm (AAA) patients is generally attributed to aneurysm rupture,[1,2] the high mortality is also present in patients with small aneurysms, in whom the risk of rupture is negligible.[3,4] Besides, the relative high mortality persists after successful preventive repair for larger aneurysms.[5] This implies that AAA disease associates with a profound excess mortality risk independent of rupture. It has been suggested that this excess mortality relates to convergence of (cardiovascular) risk factors and frailty in AAA patients.[3,6]

Over the last 20 years, the landscape of AAA management underwent profound changes. The introduction and establishment of endovascular aneurysm repair (EVAR) resulted in a significantly reduced procedural mortality.[7] Moreover, the past decades are characterized by the broad implementation of intensified cardiovascular disease risk management (CVDRM) programs with the introduction of cholesterol-lowering strategies (statins), and increased awareness on the importance of blood pressure lowering and life-style modifications (smoking cessation), which has contributed to a lower cardiovascular event rate for the general cardiovascular population.[8–10]

The question arises whether, and if so, to what extent, the changes in AAA management (EVAR and CVDRM) improved longevity of AAA patients. To address this, a time-resolved analysis of patients who underwent elective AAA repair was performed based on the Swedish National Patient Registry. With its long-lasting registration, high validity, and highly accurate mortality data,[11,12] this registry provides a unique opportunity to evaluate AAA repair epidemiology on national level. To accurately estimate AAA-specific mortality, and to address putative alterations in life-expectancy due to demographic changes over time, a relative survival analysis was applied.