Immediate Repair Compared with Surveillance of Small Abdominal Aortic Aneurysm

Background

Whether elective surgical repair of small abdominal aortic aneurysms improves survival remains controversial.

Methods

We randomly assigned patients 50 to 79 years old with abdominal aortic aneurysms of 4.0 to 5.4 cm in diameter who did not have high surgical risk to undergo immediate open surgical repair of the aneurysm or to undergo surveillance by means of ultrasonography or computed tomography every 6 months with repair reserved for aneurysms that became symptomatic or enlarged to 5.5 cm. Follow-up ranged from 3.5 to 8.0 years (mean, 4.9).

Results

A total of 569 patients were randomly assigned to immediate repair and 567 to surveillance. By the end of the study, aneurysm repair had been performed in 92.6% of the patients in the immediate-repair group and 61.6% of those in the surveillance group. The rate of death from any cause, the primary outcome, was not significantly different in the two groups (relative risk in the immediate-repair group as compared with the surveillance group, 1.21; 95% confidence interval, 0.95 to 1.54). Trends in survival did not favor immediate repair in any of the prespecified subgroups defined by age or diameter of aneurysm at entry. These findings were obtained despite a low total operative mortality of 2.7% in the immediate-repair group. There was also no reduction in the rate of death related to abdominal aortic aneurysm in the immediate-repair group (3.0%) as compared with the surveillance group (2.6%). Eleven patients in the surveillance group had rupture of abdominal aortic aneurysms (0.6% per year), resulting in seven deaths. The rate of hospitalization related to abdominal aortic aneurysm was 39% lower in the surveillance group.

Conclusions

Survival is not improved by elective repair of abdominal aortic aneurysms smaller than 5.5 cm, even when operative mortality is low.