Comparison of endovascular and open repair of ruptured abdominal aortic aneurysm in the United States in the past decade

Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms

OBJECTIVE

The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with aneurysms of the abdominal aorta and iliac arteries in succession to the 2011 and 2019 versions, with the aim of assisting physicians and patients in selecting the best management strategy.

METHODS

The guideline is based on scientific evidence completed with expert opinion on the matter. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to a modified European Society of Cardiology grading system, where the strength (class) of each recommendation is graded from I to III and the letters A to C mark the level of evidence.

RESULTS

A total of 160 recommendations have been issued on the following topics: Service standards, including surgical volume and training; Epidemiology, diagnosis, and screening; Management of patients with small abdominal aortic aneurysm (AAA), including surveillance, cardiovascular risk reduction, and indication for repair; Elective AAA repair, including operative risk assessment, open and endovascular repair, and early complications; Ruptured and symptomatic AAA, including peri-operative management, such as permissive hypotension and use of aortic occlusion balloon, open and endovascular repair, and early complications, such as abdominal compartment syndrome and colonic ischaemia; Long term outcome and follow up after AAA repair, including graft infection, endoleaks and follow up routines; Management of complex AAA, including open and endovascular repair; Management of iliac artery aneurysm, including indication for repair and open and endovascular repair; and Miscellaneous aortic problems, including mycotic, inflammatory, and saccular aortic aneurysm. In addition, Shared decision making is being addressed, with supporting information for patients, and Unresolved issues are discussed.

CONCLUSION

The ESVS Clinical Practice Guidelines provide the most comprehensive, up to date, and unbiased advice to clinicians and patients on the management of abdominal aorto-iliac artery aneurysms.

Treatment Outcomes of Patients With Ruptured Abdominal Aortic Aneurysms

BACKGROUND

Ruptured abdominal aortic aneurysm (rAAA) is a serious complication of abdominal aortic aneurysm associated with high operative mortality and morbidity rates. The present study evaluated the perioperative and long-term outcomes of Korean patients with rAAA based on national health insurance claims data.

METHODS

The National Health Insurance Service (NHIS) database was searched retrospectively to identify patients with rAAA who underwent endovascular aneurysm repair (EVAR) and open surgical repair (OSR) from 2009 to 2018. Perioperative (≤ 30 days), early postoperative (≤ 3 month), and long-term (> 3 month) survival, reinterventions, and complications were assessed.

RESULTS

The search identified 1,034 patients with rAAA, including 594 who underwent EVAR and 440 who underwent OSR. When the study period was divided into two, the total numbers of patients with rAAA, patients who underwent EVAR, and octogenarians were higher during the second half. The perioperative mortality rate was 29.8% in the EVAR and 35.0% in the OSR group (P = 0.028). Hartmann's procedure for bowel infarction was performed more frequently in the OSR than in the EVAR group (adjusted odds ratio, 6.28; 95% confidence interval [CI], 2.33-21.84; P = 0.001), but other complication rates did not differ significantly. All-cause mortality during the entire observation period did not differ significantly in the EVAR and OSR groups (adjusted hazard ratio, 1.17; 95% CI, 0.98-1.41; P = 0.087). Abdominal aortic aneurysm-related reintervention rate was significantly lower in the OSR group (adjusted hazard ratio, 0.31; 95% CI, 0.14-0.70; P = 0.005).

CONCLUSION

Although EVAR showed somewhat superior perioperative outcomes for rAAA, the long-term outcomes of EVAR after excluding initial 3 months were significantly worse than OSR. When anatomically feasible for both treatments, the perioperative mortality risk and reasonable prospects of long-term survival should be considered in rAAA.

The Management of Ruptured Abdominal Aortic Aneurysms: An Ongoing Challenge

BACKGROUND

despite improvements in the diagnosis and treatment of elective AAAs, ruptured abdominal aortic aneurysms (RAAAs) continue to cause a substantial number of deaths. The choice between an open or endovascular approach remains a challenge, as does postoperative complications in survivors. The aim of this manuscript is to offer an overview of the contemporary management of RAAA patients, with a focus on preoperative and intraoperative factors that could help surgeons provide more appropriate treatment.

METHODS

we performed a search on MEDLINE, Embase, and Scopus from 1 January 1985 to 1 May 2023 and reviewed SVS and ESVS guidelines. A total of 278 articles were screened, but only those with data available on ruptured aneurysms' incidence and prevalence, preoperative scores, and mortality rates after emergency endovascular or open repair for ruptured AAA were included in the narrative synthesis. Articles were not restricted due to the designs of the studies.

RESULTS

the centralization of RAAAs has improved outcomes after both surgical and endovascular repair. Preoperative mortality risk scores and knowledge of intraoperative factors influencing mortality could help surgeons with decision-making, although there is still no consensus about the best treatment. Complications continue to be an issue in patients surviving intervention.

CONCLUSIONS

RAAA still represents a life-threatening condition, with high mortality rates. Effective screening and centralization matched with adequate preoperative risk-benefit assessment may improve outcomes.

Endovascular aortic repair is a cost-effective option for in-hospital patients with abdominal aortic aneurysm

BACKGROUND

To investigate the cost-effectiveness of endovascular aortic repair (EVAR) versus open aortic repair (OAR) for abdominal aortic aneurysm (AAA) using incremental costs per decreased in-hospital mortality rate gained through our patients' cohort.

METHODS

Medical records and healthcare costs of patients with AAA hospitalized between 2010 and 2015 were extracted from the National Health Insurance Research Database (NHIRD) of Taiwan. Multiple regression analysis was applied to adjust for confounding factors and to compare the differences in postoperative clinical outcomes between patients who received EVAR and OAR. The incremental cost-effectiveness ratio (ICER) of EVAR was determined based on the healthcare cost obtained from the analyzed data.

RESULTS

A total of 2803 AAA patients were identified (n = 559 with ruptured AAA and n = 2244 unruptured AAA). Patients with ruptured AAA who underwent EVAR compared with OAR patients had shorter hospital and intensive care unit (ICU) stays (all p < 0.05). For patients with unruptured AAA, those who received EVAR compared with OAR, the adjusted odds ratio (aOR) of postoperative complications and in-hospital mortality were 0.371 and 0.447 (all p < 0.05). The total direct surgical costs and medical expenses during hospitalization in all AAA patients were higher for the EVAR group; however, ICER was <1 per capita gross domestic product. Stratification by age groups further suggested that ICER for patients with unruptured AAA who received EVAR, compared with OAR, decreased with age.

CONCLUSION

Total direct medical costs were higher for AAA patients receiving EVAR regardless of rupture status; however, the cost is offset by lower odds of postoperative complications and in-hospital mortality. The observed decrease in ICER with age and EVAR use warrants further analysis. Our findings further validate the use of EVAR over OAR. These results provides supporting evidence for physicians and patients with AAA to inform shared decision making regarding endovascular or OAR options.

Outcomes of emergency endovascular versus open repair for abdominal aortic aneurysm rupture

Purpose

Ruptured abdominal aortic aneurysm (rAAA) is one of the most common aortic emergencies in vascular surgery and is associated with high operative mortality and morbidity rates despite recent treatment advances. We evaluated operative mortality risks for the outcomes of emergency endovascular aneurysm repair (eEVAR) vs. open repair in rAAA.

Methods

Twenty patients underwent eEVAR (n = 12) or open repair (n = 8) for rAAA between 2016 and 2020. We adopted the EVAR first strategy since 2018. Primary endpoints included in-hospital mortality and 1-year survival. The outcome variables were analyzed with Fisher exact, Mann-Whitney test, and linear by linear association. The Kaplan-Meier method was used to estimate survival.

Results

There were 13 males (65.0%) and the median age of the study cohort was 78.0 years (range, 49–88 years). In-hospital mortality occurred in 7 patients (35.0%); 5 (50.0%) in the early period and 2 (20.0%) in the later period of this series. According to the procedure type, 4 (50.0%) and 3 (25.0%) in-hospital mortalities occurred in the open repair and eEVAR patients, respectively. In 6 patients (50.0%), eEVAR was performed on unfavorable anatomy. The 1-year survival of eEVAR vs. open repair group was 75% ± 12.5% and 50% ± 17.7%, respectively. On univariate analysis, preoperative high-risk indices, postoperative acute renal failure requiring dialysis, pulmonary complications, and prolonged mechanical ventilation were associated with higher operative mortality.

Conclusion

The current data showed relatively superior outcomes with eEVAR vs. open repair for rAAA, even in some patients with unfavorable anatomy supporting the feasibility, efficacy, and safety of EVAR first strategy.

Dose reduction using digital fluoroscopy versus digital subtraction angiography in endovascular aneurysm repair: A prospective randomized trial

OBJECTIVE

Endovascular aneurysm repair (EVAR) can result in high radiation dose to patients and operators. This prospective randomized study aimed to assess whether patient radiation dose sustained during EVAR could be decreased by predominantly using digital fluoroscopy (DF) vs the standard technique using digital subtraction angiography (DSA).

METHODS

Between February 2011 and June 2017, patients with EVAR of infrarenal abdominal aortic aneurysms were prospectively enrolled and randomly assigned to a standard treatment DSA cohort or a DF cohort in which two or fewer DSA acquisitions were allowed for confirmatory imaging. Primary end points included dose-area product (DAP) and cumulative air kerma. Secondary end points included technical success and conversion to DSA standard treatment (if DF was inadequate for visualization).

RESULTS

For all 43 patients enrolled (26 in the DF cohort, 17 in the DSA cohort), technical success was 100%. Of the 26 DF patients, 5 (19%) required conversion to the DSA cohort. In an intention-to-treat analysis, mean DAP was significantly lower in the DF cohort than in the DSA cohort (132 vs 174 Gy·cm²; P = .04). When patients were separated by number of DSA acquisitions (two or fewer vs three or more), mean DAP decreased 41% (109 vs 185 Gy·cm²; P = .005) and cumulative air kerma decreased 40% (578 vs 964 mGy; P = .004).

CONCLUSIONS

In most patients (81%), DF or limited DSA was adequate for visualization during EVAR. In both intention-to-treat DF and limited-DSA cohorts, mean DAP was significantly decreased. If image quality allows, a DF-only or limited-DSA approach to EVAR decreases radiation dose.

Palliative Care in Ruptured Aortic Aneurysm in the United States: A Retrospective Analysis of Nationwide Inpatient Sample Database

We assessed the trend of palliative care (PC) referrals and its effect on hospitalization cost and length of stay (LOS) in ruptured aortic aneurysm (rAA). The Nationwide Inpatient Sample from 2005 to 2014 was used to identify admissions with age ≥50 and rAA. A total of 54 134 rAA admissions were identified and 5019 (9.3%) had PC referrals. During the study period, PC referral rate increased from 0.97% to 15.3% ( P trend < .0001). Length of stay (1.7 vs 2.8 days, adjusted mean ratio [aMR] = 0.62, 95% confidence interval [CI]: 0.58-0.66), and cost (US$7778 vs US$13 575, aMR = 0.57, 95% CI: 0.52-0.63) were significantly lower in rAA admissions that did not undergo interventions. In the percutaneous repair group, LOS was similar but the cost was higher (US$61 759 vs US$52 260, aMR = 1.18, 95% CI: 1.05-1.30), whereas in surgical repair group, LOS was shorter (4.6 vs 5.9 days, aMR = 0.77, 95% CI: 0.73-0.82) but the cost was higher (US$59 755 vs US$52 523, aMR = 1.14, 95% CI: 1.02-1.28). Palliative care could shorten LOS and save hospitalization cost in rAA admissions not a candidate for repair. Further studies are required to investigate the variable effects of PC on rAA.

Clinical evaluation of endovascular repair of abdominal aortic aneurysm based on long-term experiences

Introduction

The endovascular method as a less invasive treatment for patients with abdominal aortic aneurysm (AAA) has become an alternative to conventional open surgery.

Aim

The objective of the present study was to analyse the outcomes of endovascular treatment of AAA patients in long-term observation.

Material and methods

A group of 236 AAA patients subjected to planned endovascular aneurysm repair (EVAR) between 2010 and 2015 was reviewed. Rates of mortality, surgical complications and re-interventions were collected in the separate time periods, i.e. up to 30 days after surgery, 30 days to 3 years, and from 3 to 5 years after surgery. Cumulative rates of these parameters were evaluated in the short-term (up to 30 days after surgery), medium-term (up to 3 years), and long-term (up to 5 years after surgery) perspective.

Results

The median age of patients was 75 years, and the most common comorbidities were arterial hypertension (54%) and ischaemic heart disease (52%). Cumulative short-, medium- and long-term mortality rates were 2.5%, 14.2% and 28.9%, respectively. Total rates of surgical complications in short-, medium- and long-term observation were 7.6%, 12.6% and 17.5%, respectively. The cumulative rate of re-interventions ranged from 4.2% to 11.4%.

Conclusions

In the consecutive time periods, the increase in the percentage of surgical complications and re-interventions increased gradually, in contrast to mortality, where the curve grew significantly, which is expected due to the aging and numerous comorbidities in the observed group of patients.

Common Sequences of Emergency Readmissions among High-Impact Users following AAA Repair

Introduction

The aim of the study was to examine common sequences of causes of readmissions among those patients with multiple hospital admissions, high-impact users, after abdominal aortic aneurysm (AAA) repair and to focus on strategies to reduce long-term readmission rate.

Methods

The patient cohort (2006–2009) included patients from Hospital Episodes Statistics, the national administrative data of all NHS English hospitals, and followed up for 5 years. Group-based trajectory modelling and sequence analysis were performed on the data.

Results

From a total of 16,973 elective AAA repair patients, 18% (n=3055) were high-impact users. The high-impact users among ruptured abdominal aortic aneurysm (rAAA) repair constituted 17.3% of the patient population (n=4144). There were 2 subtypes of high-impact users, short-term (7.2%) with initial high readmission rate following by rapid decline and chronic high-impact (10.1%) with persistently high readmission rate. Common causes of readmissions following elective AAA repair were respiratory tract infection (7.3%), aortic graft complications (6.0%), unspecified chest pain (5.8%), and gastrointestinal haemorrhage (4.8%). However, high-impact users included significantly increased number of patients with multiple readmissions and distinct sequences of readmissions mainly consisting of COPD (4.7%), respiratory tract infection (4.7%), and ischaemic heart disease (3.3%).

Conclusion

A significant number of patients were high-impact users after AAA repair. They had a common and distinct sequence of causes of readmissions following AAA repair, mainly consisting of cardiopulmonary conditions and aortic graft complications. The common causes of long-term mortality were not related to AAA repair. The quality of care can be improved by identifying these patients early and focusing on prevention of cardiopulmonary diseases in the community.

Comparative effectiveness of open surgery versus endovascular repair for hemodynamically stable and unstable ruptured abdominal aortic aneurysm

Several observational studies and randomized trials have compared open surgery (OS) and endovascular aortic repair (EVAR) for ruptured abdominal aortic aneurysm (rAAA). However, none of these studies addressed optimal management of hemodynamically (hd) unstable patients. Our objective was to compare perioperative outcomes in patients undergoing OS vs EVAR for hd-stable and hd-unstable rAAAs.This retrospective study was conducted in West China Hospital from January 2005 to December 2015. Unstable patients were defined as those who have at least 1 of the following: preoperative shock, preoperative transfusion >4 units, preoperative intubation, cardiac arrest, or unconsciousness. Univariable and multivariable logistic regression analyses were performed.Of the 102 patients, 70.6% underwent OS and 29.4% EVAR. About 46.1% were unstable, and for these patients, OS was performed in 70.2% and EVAR in 29.8%. The 30-day mortality was 23.6% (OS, 25.6%; EVAR, 18.8%; P = .585) for hd-stable patients and was 42.6% (OS, 45.5%; EVAR, 35.7%; P = .537) for hd-unstable patients. Patients with OS had longer operative time and more transfusion. Amongst hd-stable patients, OS subgroup had a higher rate of pneumonia (33.3% vs 6.3%, P = .045), longer intensive care unit (ICU) stay (43.2 vs 15.2 hours, P = .02), and length of stay (11.6 vs 8.6 days, P = .041). Among hd-unstable patients, OS subgroup had a longer ICU stay (134.3 vs 63.8 hours, P = .047). Hospitalization costs of OS group were significantly lower than those of EVAR group, regardless of hemodynamic stability.Approximately one-third of patients with rAAA were treated by EVAR at our institution. EVAR may be the preferred approach for anatomically suitable rAAAs. However, patients treated by EVAR had a similar mortality compared with those treated by OS. In addition, OS is not an independent factor for a higher 30-day mortality, and the costs of OS were much cheaper than those of EVAR. Therefore, OS is difficult to replace, especially in developing countries.

Endovascular repair versus open repair in the treatment of ruptured aortic aneurysms: a systematic review

INTRODUCTION

Rupture of abdominal aortic aneurysm remains a fatal event in up to 65% of cases and emergency open surgery (ruptured open aneurysm repair or rOAR) has a great intraoperative mortality of about 30-50%. The introduction of endovascular repair of abdominal aortic aneurysm (ruptured endovascular aneurysm repair or rEVAR) has rapidly challenged the conventional approach to this catastrophic event. The purpose of this systematic review is to compare the outcomes of open surgical repair and endovascular interventions.

EVIDENCE ACQUISITION

A literature search was performed using Medline, Scopus, and Science Direct from August 2010 to March 2017 using keywords identified and agreed by the authors. Randomized trials, cohort studies, and case-report series were contemplated to give a breadth of clinical data.

EVIDENCE SYNTHESIS

Ninety-three studies were included in the final analysis. Thirty-five (50.7%) of the listed studies evaluating the within 30 days mortality rates deposed in favor of rEVAR, while the others (comprising all four included RCTs) failed detecting any difference. Late mortality rates were found to be lower in rEVAR group in seven on twenty-seven studies (25.9%), while one (3.7%) reported higher mortality rates following rEVAR performed before 2005, one found lower incidence of mortality at 6 months in the endovascular group but higher rates in the same population at 8 years of follow-up, and the remaining (66.7%) (including all three RCTs) failed finding any benefit of rEVAR on rOAR. A lower incidence of complications was reported by thirteen groups (46.4%), while other thirteen studies did not find any difference between rEVAR and rOAR. Each of these two conclusions was corroborated by one RCTs. Other two studies (7.2%) found higher rates of tracheostomies, myocardial infarction, and acute tubular necrosis or respiratory, urinary complications, and acute renal failure respectively in rOAR group. The majority of studies (59.0%, 72.7%, and 89.3%, respectively) and all RCTs found significantly lower rates of length of hospitalization, intensive care unit transfer, and blood loss with or without transfusion need in rEVAR group. The large majority of the studies did not specified neither the type nor the brands of employed stent grafts.

CONCLUSIONS

The bulk of evidence regarding the comparison between endovascular and open surgery approach to RAAA points to: 1) non-inferiority of rEVAR in terms of early (within 30 days) and late mortality as well as rate of complications and length of hospitalization, with trends of better outcomes associated to the endovascular approach; 2) significantly better outcomes in terms of intensive care unit transfer and blood loss with or without transfusion need in the rEVAR group. These conclusions reflect the results of the available RCTs included in the present review. Thus rEVAR can be considered a safe method in treating RAAA and we suggest that it should be preferred when technically feasible. However, more RCTs are needed in order to give strength of these evidences, bring to definite clinical recommendations regarding this subject, and assess the superiority (if present) of one or more brands of stent grafts over the others.

Multiplanar Computed Tomography of Vascular Etiologies of Acute Abdomen: A Pictorial Review

Acute abdomen is a common presentation in the emergency department and radiologic imaging plays a pivotal role in the evaluation of such patients. Multi-detector computed tomography (MDCT) is the most commonly utilized radiologic investigation in such patients as it can be performed fairly rapidly and has excellent accuracy for diagnosing various causes of an acute abdomen. Additionally, MDCT may also reveal clues towards an alternative diagnosis that was not even suspected on the basis of a history and physical examination. Consequently, it is indispensable for radiologists to be able to accurately and efficiently recognize imaging features of disorders that may present as an acute abdomen. While gastrointestinal, hepatobiliary and genitourinary causes account for most cases of acute abdomen, vascular etiologies may also be implicated in a small-but significant-proportion of cases. Therefore, in this pictorial review, we describe the typical MDCT imaging features of various vascular etiologies that may present as an acute abdomen.

Short-term outcomes of endovascular repair of abdominal aortic aneurysm, including ruptured cases

Introduction

Endovascular aneurysm repair as a minimally invasive alternative has become a commonly used surgical method for treating patients with abdominal aortic aneurysm (AAA).

Aim

To analyze short-term outcomes of endovascular treatment of AAA patients, including ruptured cases.

Material and methods

From 2010 to 2015, 247 patients with AAA were treated using the endovascular aneurysm repair technique. A short-term analysis was conducted – up to 30 days after surgery. It included 236 patients with planned surgery and 11 operated on in emergency mode, due to ruptured AAA.

Results

Rates of short-term mortality and re-interventions among patients undergoing planned surgery were 2.5% and 4.2%, respectively. Surgical complications occurred in 18 (7.6%) patients, with the most common being thrombosis and blockage of the stent graft (2.5%). Systemic complications were found in 19 (8%) planned cases, with the most common being arrhythmias (1.7%). In patients with ruptured AAA, short-term mortality was 36.4%, while re-interventions were performed in 3 (27.3%) patients. Rates of surgical and systemic complications for ruptured AAA were 45.4% and 72.7%, respectively.

Conclusions

The AAA patients undergoing endovascular aneurysm repair showed relatively low short-term mortality. However, larger groups of patients with ruptured AAA are required in order to assess the outcomes in this sub-population.

Open Abdomen Therapy with Vacuum and Mesh Mediated Fascial Traction After Aortic Repair: an International Multicentre Study

OBJECTIVES

Open abdomen therapy may be necessary to prevent or treat abdominal compartment syndrome (ACS). The aim of the study was to analyse the primary delayed fascial closure (PDFC) rate and complications after open abdomen therapy with vacuum and mesh mediated fascial traction (VACM) after aortic repair and to compare outcomes between those treated with open abdomen after primary versus secondary operation.

METHODS

This was a retrospective cohort, multicentre study in Sweden, Finland, and Norway, including consecutive patients treated with open abdomen and VACM after aortic repair at six vascular centres in 2006-2015. The primary endpoint was PDFC rate.

RESULTS

Among 191 patients, 155 were men. The median age was 71 years (IQR 66-76). Ruptured abdominal aortic aneurysm (RAAA) occurred in 69.1%. Endovascular/hybrid and open repairs were performed in 49 and 142 patients, respectively. The indications for open abdomen were inability to close the abdomen (62%) at primary operation and ACS (80%) at secondary operation. Duration of open abdomen was 11 days (IQR 7-16) in 157 patients alive at open abdomen termination. The PDFC rate was 91.8%. Open abdomen initiated at primary (N=103), compared with secondary operation (N=88), was associated with less severe initial open abdomen status (p=.006), less intestinal ischaemia (p=.002), shorter duration of open abdomen (p=.007), and less renal replacement therapy (RRT, p<.001). In hospital mortality was 39.3%, and after entero-atmospheric fistula (N=9) was 88.9%. Seven developed graft infection within 6 months, 1 year mortality was 28.6%. Intestinal ischaemia (OR 3.71, 95% CI 1.55-8.91), RRT (OR 3.62, 95% CI 1.72-7.65), and age (OR 1.12, 95% CI 1.06-1.12), were independent factors associated with in hospital mortality, but not open abdomen initiated at primary versus secondary operation.

CONCLUSIONS

VACM was associated with a high PDFC rate after prolonged open abdomen therapy following aortic repair. Patient outcomes seemed better when open abdomen was initiated at primary, compared with secondary operation but a selection effect is possible.

Effectiveness of open versus endovascular abdominal aortic aneurysm repair in population settings: A systematic review of statewide databases

BACKGROUND

Patient outcomes after open abdominal aortic aneurysm and endovascular aortic aneurysm repair have been widely reported from several large, randomized, controlled trials. It is not clear whether these trial outcomes are representative of abdominal aortic aneurysm repair procedures performed in real-world hospital settings across the United States. This study was designed to evaluate population-based outcomes after endovascular aortic aneurysm repair versus open abdominal aortic aneurysm repair using statewide inpatient databases and examine how they have helped improve our understanding of abdominal aortic aneurysm repair.

METHODS

A systematic search of MEDLINE, EMBASE, and CINAHL databases was performed to identify articles comparing endovascular aortic aneurysm repair and open abdominal aortic aneurysm repair using data from statewide inpatient databases. This search was limited to studies published in the English language after 1990, and abstracts were screened and abstracted by 2 authors.

RESULTS

Our search yielded 17 studies published between 2004 and 2016 that used data from 29 different statewide inpatient databases to compare endovascular aortic aneurysm repair versus open abdominal aortic aneurysm repair. These studies support the randomized, controlled trial results, including a lower mortality associated with endovascular aortic aneurysm repair extended from the perioperative period up to 3 years after operation, as well as a higher complication rate after endovascular aortic aneurysm repair. The evidence from statewide inpatient database analyses has also elucidated trends in procedure volume, patient case mix, volume-outcome relationships, and health care disparities associated with endovascular aortic aneurysm repair versus open abdominal aortic aneurysm repair.

CONCLUSION

Population analyses of endovascular aortic aneurysm repair and open abdominal aortic aneurysm repair using statewide inpatient databases have confirmed short- and long-term mortality outcomes obtained from large, randomized, controlled trials. Moreover, these analyses have allowed us to assess the effect of endovascular aortic aneurysm repair adoption on population outcomes and patient case mix over time.

Endovascular versus open repair of ruptured abdominal aortic aneurysm

INTRODUCTION

Endovascular aneurysm repair (EVAR) is a comparatively less invasive technique than open repair (OR). Debate remains with regard to the benefit of EVAR for patients with ruptured abdominal aortic aneurysm (RAAA). We sought to evaluate and report outcomes of EVAR for RAAA in an Irish tertiary vascular referral centre.

METHODS

Patients undergoing emergency surgery for ruptured or symptomatic AAA were identified from theatre logbooks and HIPE database. Retrospective chart review was undertaken. Data were exported to IBM SPSS version 21 for statistical analysis with p < 0.05 considered significant.

RESULTS

A total of 41 patients underwent surgery for RAAA. The mean age was 74 years old with a range from 55 to 89 years. The majority (n = 25, 61%) were baseline American Society of Anaesthesiology (ASA) grade 3-4. Of these 56% underwent EVAR with the remaining 44% repaired open. Mortality rate in those undergoing emergency EVAR was 34.8%, compared with 38.9% in those undergoing open surgery. This difference was not statistically significant. The mean overall length of stay was 13 days. With regard to prognostic indicators of patient outcome, increasing patient age was noted to be significantly associated with increased mortality (p = 0.013), as was increased ASA score at time of surgery (p = 0.029).

CONCLUSIONS

Mortality rates in those undergoing EVAR for RAAA are comparable with those undergoing open repair. Increasing age and ASA score are significant predictors of mortality in patients with RAAA undergoing intervention.

Endovascular vs. Open Repair for Ruptured Abdominal Aortic Aneurysm

Background

Patients presenting with ruptured abdominal aortic aneurysms are most often treated with open repair despite the fact that endovascular aneurysm repair is a less invasive and widely accepted method with clear benefits for elective aortic aneurysm patients. A debate exists regarding the definitive benefit in endovascular repair for patients with a ruptured abdominal aortic aneurysm. The aim of this literature review was to determine if any trends exist in favor of either open or endovascular repair.

Material/Methods

A literature search was performed using PUBMED, OVID, and Google Scholar databases. The search yielded 64 publications.

Results

Out of 64 publications, 25 were retrospective studies, 12 were population-based, 21 were prospective, 5 were the results of RCTs, and 1 was a case-series. Sixty-one studies reported on early mortality and provided data comparing endovascular repair (rEVAR) and open repair (rOR) for ruptured abdominal aneurysm groups. Twenty-nine of these studies reported that rEVAR has a lower early mortality rate. Late mortality after rEVAR compared to that of rOR was reported in 21 studies for a period of 3 to 60 months. Results of 61.9% of the studies found no difference in late mortality rates between these 2 groups. Thirty-nine publications reported on the incidence of complications. Approximately half of these publications support that the rEVAR group has a lower complication rate and the other half found no difference between the groups. Length of hospital stay has been reported to be shorter for rEVAR in most studies. Blood loss and need for transfusion of either red cells or fresh frozen plasma was consistently lower in the rEVAR group.

Conclusions

Differences between the included publications affect the outcomes. Randomized control trials have not been able to provide clear conclusions. rEVAR can now be considered a safe method of treating rAAA, and is at least equal to the well-established rOR method.

Current treatment strategies for ruptured abdominal aortic aneurysm

BACKGROUND

Ruptured abdominal aortic aneurysm (rAAA) represents one of the most challenging emergencies in surgery. Open repair (OR) is associated with relevant morbidity and mortality and has not been reduced significantly over the last decade. The introduction of endovascular aneurysm repair (EVAR) and its meanwhile common use in the treatment of rAAA has raised the demand for randomised controlled trials (RCTs) in order to resolve a potential superiority of either OR or EVAR.

PURPOSE

This review discusses the current treatment strategies in rAAA repair including diagnostics, peri-operative management and results of OR and EVAR, focussing on RCTs comparing both modalities.

RESULTS

Thirty-day mortality after OR and EVAR shows no significant difference in published RCTs. In particular with respect to OR, 30-day mortality was much lower than anticipated throughout all RCTs ranging from 18 to 37 %. EVAR for rAAA resulted in reduced in-hospital stay. Limitations of all except one RCT are low patient recruitment and exclusion of haemodynamically unstable patients.

CONCLUSIONS

OR and EVAR need to be provided for rAAA. Despite lacking evidence, EVAR is the first choice treatment in experienced high-volume vascular centres. Low mortality rates in all RCTs raise the question if aortic surgery should be centralised.

Emergent Endovascular Stent Grafts for Ruptured Aortic Aneurysms

Ruptured aortic aneurysms uniformly require emergent attention. Historically, urgent surgical repair or medical management was the only treatment options. The development of covered stent grafts has introduced a third approach in the care of these critical patients. The clinical status of the patient and local physician expertise drive the treatment modalities in the majority of cases. The goal of therapy in these patients is to stabilize the patient as quickly as possible, establish maximum survival with minimum morbidity, and provide a long lasting result. The endovascular approach has become an acceptable treatment option in an increasing number of patients presenting with ruptured aneurysmal disease of both the descending thoracic and abdominal aorta. Major factors influencing treatment include patient clinical status, characteristics of the aorta, physician preference, institutional experience, and availability of appropriate equipment. Planning, experience, and the ability to improvise effective solutions are keys to the success of the procedure when endovascular techniques are utilized. Three separate cases, requiring intraprocedural improvisation, are presented followed by a review of the literature.

Aortic Dehiscence During Endovascular Sealing for Ruptured Abdominal Aortic Aneurysms

PURPOSE

To present a case of aneurysm disruption during endovascular sealing of a ruptured abdominal aortic aneurysm.

CASE REPORT

A 91-year-old woman presented with a ruptured abdominal aortic aneurysm. Her aneurysm morphology was unsuitable for standard or fenestrated endovascular repair, whereas open repair was considered to have an increased perioperative risk owing to multiple comorbidities. The Nellix endovascular sealing system was used. The balloon-expandable stent-grafts were deployed, but in the presence of aneurysm rupture, it was decided not to prefill the endobags with saline. The patient developed hypotension during endobag filling, which resolved once target pressure was reached. The procedure was completed uneventfully, and the completion angiogram revealed no endoleak. The time from guidewire insertion to completion angiogram was 24 minutes. Over the following days, she developed a gradual drop in hemoglobin, and computed tomographic angiography revealed an increased retroperitoneal hematoma and pronounced disruption of the calcified rim of the aortic sac compared to the preoperative imaging. She was managed with supportive treatment, demonstrating remarkable progress. She remains in good health 4 months later.

CONCLUSION

Endovascular sealing can be used in patients with ruptured abdominal aortic aneurysm. Intraoperative endobag saline prefill should be avoided to minimize the risk of aortic wall disruption.

Persistent endoleak after endovascular aneurysm repair for acute Q-fever-infected aortocaval fistula

We present a case of an endovascular aneurysm repair for a Q-fever-infected acute abdominal aortic aneurysm with aortocaval fistula. Type 2 endoleak persisted after successful endovascular repair.

Effects of weekend admission on the outcomes and management of ruptured aortic aneurysms

OBJECTIVE

Ruptured aortic aneurysm is a condition with a high rate of mortality that requires prompt surgical intervention. It has been noted that in some conditions requiring such prompt intervention, in-hospital mortality is increased in patients admitted on the weekends compared with patients admitted on weekdays. We sought to determine if this was indeed the case for both ruptured thoracic aortic aneurysms (TAA) and abdominal aortic aneurysms (AAA) and to elucidate the possible reasons.

METHODS

Using the Nationwide Inpatient Sample, a publicly available database of inpatient care, we analyzed the incidence of mortality among 7200 patients admitted on the weekends compared with weekdays for ruptured aortic aneurysm. Among these patients, 19% had a TAA and 81% had an AAA, and each group was analyzed for differences in mortality during the hospitalization. We adjusted for demographics, comorbid conditions, hospital characteristics, rates of surgical intervention, timing of surgical intervention, and use of additional therapeutic measures.

RESULTS

Patients admitted on the weekend for both ruptured TAA and AAA had a statistically significant increase in mortality compared with those admitted on the weekdays (TAA: odds ratio, 2.55; 95% confidence interval, 1.77-3.68; P = .03; AAA: odds ratio, 1.32; 95% confidence interval, 1.13-1.55; P = .0004). Among those with TAA, a surgical intervention was performed on day of admission in 62.1% of weekday admissions vs 34.9% of weekend admissions (P < .0001). This difference was much smaller among those with an aortic aneurysm; 79.6% had a surgical intervention on day of admission on a weekday vs 77.2% on the weekend (P < .0001).

CONCLUSIONS

Weekend admission for ruptured aortic aneurysm is associated with an increased mortality compared with admission on a weekday, and this is likely due to several factors including a delay in prompt surgical intervention.