Kak Khee Yeung
Current Position
Vascular surgeon / Associate professor Vascular Surgery
Amsterdam UMC
Abdominal Aorta & Aortic iliac Session

Topic: Bad necks in aortic aneurysms leads to higher mortality rates, long term results from the Dream trial


After the initial survival benefit for endovascular aneurysm repair (EVAR) compared to open repair (OR), long-term survival rates leveled. Despite a persistent risk for secondary interventions after EVAR, especially in patients with unfavorable neck morphology. In this study, the association of unfavorable neck morphology on long-term survival after both open and endovascular repair for elective infrarenal abdominal aortic aneurysms was investigated in patients enrolled in the Dutch Randomized Endovascular Aneurysm Management (DREAM)-trial.
A post-hoc on-treatment analysis was performed in all patients randomized in the DREAM-trial. The aneurysm severity grading (ASG)-neck score, previously associated with increased risk for secondary interventions, was used to indicate favorable (ASG-neck score 4) and unfavorable (ASG-neck score 5) aneurysm neck morphology in both groups. Survival was compared with Kaplan-Meier analysis, differences were calculated using log-rank tests. Risk-adjusted survival was analyzed using a Cox proportional-hazards model. Causes of death were compared by use of an event per person-year analysis.
After OR 24 out of 173 (13.9%) and after EVAR 30 out of 171 (17.5%) had unfavorable neck morphology (p=0.34). After OR, 12 year survival rates were 47.1% and 20.8% for favorable and unfavorable neck groups, respectively, difference 26.3% (95%CI 8.2-44.4; p=0.003). After EVAR, 12 year survival rates were 41.0% and 30.0%, difference 11.0% (95%CI -7.4-29.4; p=0.3). Multivariate analysis of unfavorable neck patients showed a significant reduction in mortality after EVAR, odds ratio 2.3 (95%CI 1.2-4.8; p=0.02). An increased number of cardiovascular deaths were observed in patients with unfavorable neck morphology after OR and EVAR.
Patients with long life expectancy should preferably be treated by standard endovascular repair or suprarenal alternatives. Cardiovascular risk management and pre-operative screening should be intensified in all patients with unfavorable neck morphology.