Association between Diabetes Status and Long-term Outcomes Following Open and Endovascular Repair of Infrarenal Abdominal Aortic Aneurysms.

ABSTRACT

OBJECTIVE: Current literature reports conflicting findings regarding the effect of diabetes mellitus (DM) on outcomes of AAA repair. In this study we examined the effect of DM and its management on outcomes following open (OAR) and endovascular (EVAR) AAA repair. METHODS: We identified all patients undergoing OAR or EVAR for infrarenal AAA between 2003-2018 in the Vascular Quality Initiative (VQI) registry data linked with Medicare claims. We excluded patients with missing DM status. Patients were stratified by their preoperative DM status, and then further stratified by DM management dietary, non-insulin anti-diabetic medications (NIM), or insulin. Outcomes of interest included one-year aneurysm sac dynamics, 8-year aneurysm rupture, reintervention, and all-cause mortality. These outcomes were analyzed with chi-square, Kaplan-Meier methods, and multivariable cox regression analyses. RESULTS: We identified 34,021 EVAR patients and 4,127 OAR patients of which 20% and 16% had DM, respectively. Of all DM patients, 22% were managed by dietary management, 59% by NIM, and 19% by insulin. Following EVAR, DM patients were more likely to have stable sacs while non-DM patients were more likely to have sac regression at 1 year. Compared with non-DM, DM was associated with a significantly lower risk for 8-year rupture in EVAR (EVAR HR 0.68 [0.51-0.92]). Compared with non-DM, NIM was associated with lower risk of rupture within 8-years for both EVAR and OAR (EVAR HR 0.64 [0.44-0.94]; OAR HR 0.29 [0.41-0.80]), while dietary and insulin had similar rupture risk compared with non-DM. However, compared with non-DM, DM was associated with higher risk of 8-year all-cause mortality following EVAR and OAR (DM vs. non-DM EVAR HR 1.17 [1.11-1.23]; OAR HR 1.16 [1.00-1.36]). Following further DM management sub-stratification, compared with non-DM, management with NIM and insulin were associated with higher 8-year mortality in EVAR and OAR (EVAR NIM HR 1.12 [1.05-1.20] & insulin HR 1.40 [1.26-1.55]; OAR NIM HR 1.27 [1.06-1.54] & insulin HR 1.57 [1.15-2.13]). Finally, there was a similar risk of reintervention across the DM and non-DM populations in EVAR and OAR. CONCLUSION: DM was associated with lower adjusted risk of rupture following EVAR as well as OAR in patients managed with NIM. Nevertheless, just as in patients without AAA, preoperative DM was associated with a higher adjusted risk of all-cause mortality. Further study is needed to evaluate for differences in aneurysm-related mortality between DM and non-DM, and studies are planned to evaluate the independent effect of NIM on aneurysm-related outcomes.