Abdominal Aortic Aneurysm Repair in the Brazilian Public Healthcare System: A 10-Year Analysis of Outcomes

BACKGROUND: The majority of studies evaluating outcomes after abdominal aortic aneurysm (AAA) repair originate from high-income countries. In Brazil, a middle-income country, the public healthcare system (Sistema Único de Saúde; SUS) is the primary provider of high-complexity inpatient care. This study examines 10-year trends in AAA repair within SUS. METHODS: DATASUS, the information technology department of SUS, was queried using procedure-specific codes for open (OAR) and endovascular aneurysm repairs (EVAR) performed between 2014 to 2023. Procedures were stratified by timing of intervention (elective vs. non-elective), sex and ethnicity. We calculated the annual and 10-year means for procedure volume, length of stay, in-hospital mortality, inflation-adjusted expenditure, and reimbursement for each procedure type. Trends over the decade were analyzed using chi-square and t tests. RESULTS: Of 11,140 AAA repairs performed from 2014 to 2023, 69.6% were EVAR and 59.2% were non-elective. Overall annual number of AAA repairs declined 28.6% from 1,430 in 2014 to 1,021 in 2023. Concurrently, the proportion of elective AAA repairs decreased from 46.6% to 41.6% and the proportion of OAR increased from 26.8% to 34.7%. Most patients were male (75.9%) and White (56.9%). Mean in-hospital mortality was higher after OAR than EVAR (40.3% non-elective OAR vs. 7.3% non-elective EVAR; and 16.0% elective OAR vs. 2.6% elective EVAR). Mean LOS declined 29.3% for elective procedures. The annual expenditure on AAA repair decreased 80.3%, with 92.0% spent on EVAR. Hospital reimbursement per EVAR procedure decreased 81.3% while OAR decreased 66.8%. CONCLUSION: There was a 28.6% decrease in number of AAA repairs performed in the Brazilian public healthcare system over the past decade. This was associated with an increase in in-hospital mortality and decrease in LOS and reimbursement. Our results suggest a gap in AAA care in Brazil and raise concerns for an increasing number of untreated patients.