Highlights
- •Retrospective data collected within the Vascular Quality Initiative (VQI).
- •Isolated statin and statin + AP therapy studied in AAA patient outcomes.
- •Most AAA patient populations under study showed significant survival benefit.
- •Statin recommendations within aneurysm treatment guidelines may need revision.
Background
Statin therapy has been associated with improved clinical outcomes in patients undergoing
treatment for vascular disease. Current guidelines do not address statin therapy in
isolated abdominal aortic aneurysm (AAA) in the absence of other atherosclerotic cardiovascular
disease (ASCVD). This study aims to elucidate effects of statin therapy, either as
monotherapy or combined with antiplatelet agents, on the long-term mortality of patients
with and without ASCVD who undergo elective AAA repair.
Methods
A retrospective review was performed on all AAA patients treated electively with endovascular
(EVAR) and open aortic repair (OAR) in the Society for Vascular Surgery Vascular Quality
Initiative from 2003–2020. Long-term mortality was evaluated based on the presence
of statin and antiplatelet medication use at discharge stratified by those with and
without a history of ASCVD. Unadjusted survival was estimated by Kaplan Meier methodology.
Cox proportional hazards modeling was used to determine mortality risk after adjusting
for key factors.
Results
A total of 47,012 AAA repairs were selected for analysis: 80.7% EVAR (N = 40,153) and 19.3% OAR (N = 6,859). EVAR patients on combined statin/antiplatelet (AP) therapy had significantly
better survival irrespective of whether they had known ASCVD. In the presence of ASCVD,
EVAR patients on statin alone had improved survival compared to those not on a statin
(10.9 ± 0.5 vs. 10.5 ± 0.4 years, Log Rank < 0.001), with survival being even greater
among those receiving combined statin/AP therapy (12.2 ± 0.2 vs. 10.5 ± 0.4 years,
Log Rank < 0.001). In the absence of ASCVD, EVAR patients on statin alone also had
better mean survival compared to patients not on a statin (8.7 ± 0.5 vs. 8.4 ± 0.4
years, Log Rank<.001), with higher survival among statin/AP therapy patients (9.4
± 0.2 years vs. 8.7 ± 0.5 years, Log Rank < 0.001). Comparison of adjusted survival
via Cox multivariable regression demonstrated a protective effect of statins (HR = 0.737,
P = 0.04, vs. no medication) and combined statin/AP therapy (HR = 0.659, P = 0.001, vs no medication) in patients with ASCVD history. A similar protective effect
(statin: HR 0.826, P = 0.05. Combination statin/AP: HR 0.726, P < 0.001, vs. no medication) was identified in patients without ASCVD history.
Within the OAR cohort, statin therapy was not associated with improved survival among
patients without ASCVD; however, combined statin/AP therapy had a protective effect
for patients with a known ASCVD diagnosis. Based on KM analysis, OAR patients with
ASCVD on combined statin/AP therapy had significantly higher mean survival compared
to isolated statin therapy (12.7 ± 0.2 vs. 10.3 ± 0.65 years) and no medical therapy
(10.5 ± 0.8 years, Log Rank < 0.001). In KM analysis, OAR patients without known ASCVD
indications (N = 3591) had no significant survival differences based on the presence of combined
statin/AP therapy (8.4 ± .07 vs. 8.5 ± .11 years, Log Rank = 0 638).
Conclusion
Isolated statin therapy and combined statin/AP therapy showed significant survival
benefit in all EVAR and OAR patients with ASCVD indications, as well as among EVAR
patients without a known ASCVD diagnosis. OAR patients without ASCVD did not have
a significant survival benefit from statin therapy, but low numbers in this group
may have confounded the findings. Combined statin/AP therapy appears to have significant
post-repair survival benefits even in isolated AAA without ASCVD, as demonstrated
in post-EVAR patients in this study. Expansion of statin use recommendations within
aneurysm treatment guidelines may be warranted.
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Article Info
Publication History
Published online: January 29, 2022
Accepted:
January 10,
2022
Received in revised form:
January 9,
2022
Received:
August 15,
2021
Footnotes
Conflict of Interest: The authors declare no conflicts of interest
Identification
Copyright
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