Open versus Endovascular Repair of Ruptured Abdominal Aortic Aneurysms

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.

The sandwich technique to preserve the internal iliac artery during EVAR for ruptured abdominal aortic aneurysm with congenital anomalies

Congenital abnormalities of the iliac artery are uncommon and often discovered incidentally during the diagnosis or treatment of peripheral vascular diseases such as abdominal aortic aneurysm (AAA) and peripheral arterial diseases. The endovascular treatment of infrarenal AAA can be complicated by anatomic abnormalities in the iliac arteries, such as the absence of the common iliac artery (CIA) or overly short bilateral common iliac arteries. We present a case of a patient with a ruptured AAA and bilateral absence of the CIA, successfully treated by endovascular intervention combined with preservation of the internal iliac artery using the sandwich technique.

Sex Differences in Outcomes Following Ruptured Abdominal Aortic Aneurysm Repair

IMPORTANCE

Sex differences in aortic surgery outcomes are commonly reported. However, data on ruptured abdominal aortic aneurysm (rAAA) repair outcomes in women vs men are limited.

OBJECTIVE

To assess differences in perioperative and long-term mortality following rAAA repair in women vs men.

DESIGN, SETTING, AND PARTICIPANTS

A multicenter, retrospective cohort study was conducted using the Vascular Quality Initiative database, which prospectively captures information on patients who undergo vascular surgery across 796 academic and community hospitals in North America. All patients who underwent endovascular or open rAAA repair between January 1, 2003, and December 31, 2019, were included. Outcomes were assessed up to January 1, 2020.

EXPOSURES

Patient sex.

MAIN OUTCOMES AND MEASURES

Demographic, clinical, and procedural characteristics were recorded, and differences between women vs men were assessed using independent t test and χ2 test. The primary outcomes were in-hospital and 8-year mortality. Associations between sex and outcomes were analyzed using univariable and multivariable logistic regression and Cox proportional hazards regression analysis.

RESULTS

A total of 1160 (21.9%) women and 4148 (78.1%) men underwent rAAA repair during the study period. There was a similar proportion of endovascular repairs in women and men (654 [56.4%] vs 2386 [57.5%]). Women were older (mean [SD] age, 75.8 [9.3] vs 71.7 [9.6] years), more likely to have chronic kidney disease (718 [61.9%] vs 2184 [52.7%]), and presented with ruptured aneurysms of smaller diameters (mean [SD] 68 [18.2] vs 78 [30.2] mm). In-hospital mortality was higher in women (34.4% vs 26.6%; odds ratio, 1.44; 95% CI, 1.25-1.66), which persisted after adjusting for demographic, clinical, and procedural characteristics (adjusted odds ratio, 1.36; 95% CI, 1.12-1.66; P = .002). Eight-year survival was lower in women (36.7% vs 49.5%; hazard ratio, 1.25; 95% CI, 1.04-1.50; P = .02), which persisted when stratified by endovascular and open repair. This survival difference existed in both the US and Canada. Variables associated with long-term mortality in women included older age and chronic kidney disease.

CONCLUSIONS AND RELEVANCE

Women who underwent rAAA repair had higher perioperative and 8-year mortality rates following both endovascular and open repair compared with men. Older age and higher rates of chronic kidney disease in women were associated with higher mortality rates. These findings suggest that future studies should assess the reasons for these disparities and whether opportunities exist to improve AAA care for women.

A comparison of endovascular versus open repair for ruptured abdominal aortic aneurysm - Meta-analysis of propensity score-matched data

BACKGROUND

Optimal management of ruptured abdominal aortic aneurysms (rAAA) has been heavily debated in the literature. The aim of this review is to assess comparative outcomes from propensity-matched studies of endovascular versus open for rAAA.

METHODS

Electronic databases (MEDLINE and Embase) were searched in January 2021 using the Healthcare Databases Advanced Search interface. Eligible studies compared endovascular versus open repair for rAAA using propensity-matched cohorts. Pooled estimates of perioperative outcomes were calculated using odds ratio (OR) or mean difference (MD) and 95% confidence interval (CI) using the random-effects model. Time-to-event data meta-analysis was conducted using the inverse-variance method and reported as summary hazard ratio (HR) and associated 95% CI. The quality of evidence was graded using a system developed by the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) working group.

RESULTS

Six studies published between 2010 and 2020 were selected for qualitative and quantitative synthesis, reporting a total of 6731 patients. The odds of perioperative mortality after endovascular aneurysm repair (EVAR) were significantly lower than after open surgical repair (OSR) (OR 0.52, 95% CI 0.41-0.65). The hazard of overall mortality during follow-up was lower, although not significantly, after EVAR than after OSR (HR 0.79, 95% CI 0.62-1.01). The odds of acute kidney injury and early aneurysm-related reintervention were both significantly lower after EVAR than after OSR (OR 0.34, 95% CI 0.14-0.78 and OR 0.57, 95% CI 0.33-0.98, respectively). Patients treated with EVAR stayed in hospital for significantly less time than those treated with OSR (MD -5.13, 95% CI -7.94 to -2.32). The certainty of the body of evidence for perioperative mortality was low and for overall mortality was very low.

CONCLUSION

The evidence suggests that EVAR confers a significant benefit on perioperative mortality.

Hybrid emergency room management of a ruptured abdominal aortic aneurysm

Patients with a ruptured abdominal aortic aneurysm (rAAA) still have high mortality. Rapid diagnosis and treatment are vital for improving survival outcomes. rAAA management has evolved regarding these factors. We have reported the case of a 70-year-old man with an rAAA that was rapidly diagnosed and treated in a hybrid emergency room (ER). A hybrid ER is an integrated ER capable of computed tomography scanning, interventional radiology, and surgery in one place. In the present case, the door-to-intervention time was 35 minutes. The use of hybrid ERs has the potential to enhance the speed and quality of diagnostic and definitive treatment of rAAAs.

Endovascular Repair of a Ruptured Thoracoabdominal Aortic Aneurysm With the Sandwich Technique: A Case Report

INTRODUCTION

aortic aneurysms involving the renal and visceral arteries are endovascular challenges, especially for emergencies. We report a case of ruptured thoracoabdominal aortic aneurysm (TAAA) in a morbidly obese 71-year-old man. The patient was admitted with a stable hemodynamic state. A computed tomography angiogram (CTA) revealed a contained ruptured TAAA with an occluded celiac trunk and left renal artery due to previous nephrectomy. Due to the emergency and his comorbidities, we performed an endovascular aortic repair with the sandwich technique and 2 chimneys. Two bridging stents (chimneys) were deployed between the aorta and the target vessels (superior mesenteric and right renal arteries) in a space created in-between 2 aortic straight endografts. Ten days postoperative, acute renal failure appeared and right renal stent occlusion was diagnosed on CTA. Unfortunately, no adequate kidney revascularization could be obtained, requiring permanent hemodialysis. At a 3-month follow-up visit, the patient did well with stable aneurysm dimensions.

CONCLUSIONS

encouraging outcomes of chimney-EVAR techniques, comparable to those in published reports of fenestrated-EVAR and branched-EVAR, support this procedure as a valid off-the-shelf available alternative in emergency situations. Nevertheless, only few midterm results achieved are actually available and long-term outcomes are actually unknown.

Inferior Vena Cava Compression Caused by a Retroperitoneal Hematoma Following an Abdominal Aortic Aneurysm Rupture

This report presents the case of a 43-year-old man with inferior vena cava (IVC) compression caused by a retroperitoneal hematoma following an abdominal aortic aneurysm (AAA) rupture. Preoperative computed tomography scans revealed an infrarenal AAA with a retroperitoneal hematoma nearly occluding the IVC. After emergency aortic grafting, IVC thrombosis, deep venous thrombosis (DVT), and pulmonary thromboembolism (PTE) arose. Anticoagulation therapy resolved these thrombotic complications. Disappearance of the hematoma and IVC recanalization were confirmed 3 months postoperatively. Although IVC compression caused by a retroperitoneal hematoma is temporary, careful attention should be paid to IVC thrombosis, DVT, and PTE as possible complications.

Open Versus Endovascular Repair of Isolated Iliac Artery Aneurysms

PURPOSE:

Outcomes of open iliac artery repair (OIR) and endovascular iliac artery repair (EVIR) were compared at a tertiary referral vascular center.

METHODS:

From 2004 to 2015, all patients treated for isolated iliac artery aneurysms (IAAs) were retrospectively identified, and patient records and computed tomography (CT) scans were analyzed. The primary end point was overall survival; secondary end points were 30-day mortality and morbidity and freedom from reintervention. For follow-up, data from outpatient visits and CT scans following a standard surveillance protocol were used.

RESULTS:

A total of 106 IAAs in 94 patients were treated (mean follow-up: 35.7 months; 66 OIR; 40 EVIR). Six (15%) aneurysms from the EVIR group and 4 (6.1%) from open-operated IAA presented in the state of rupture. There was no difference in overall survival between EVIR and OIR ( P = .14). In multivariable analysis, higher risk of death was associated with ruptured IAA (rIAA; hazard ratio [HR]: 40.44, 95% confidence interval [CI]: 2.05-796.18; P = .02) and coronary heart disease (HR: 11.07, 95% CI: 1.94-63.36; P < .01). The 30-day mortality was 1.9% overall (0% OIR, 5.0% EVIR, P = .27), but there were no differences between OIR and EVIR in 30-day morbidity ( P = .11). Freedom from reintervention was higher for OIR than for EVIR ( P < .01). In multivariable analysis, a higher reintervention rate was seen in EVIR (HR: 10.80, 95% CI: 2.20-53.01; P < .01) and in rIAA (HR: 12.02, 95% CI: 1.31-111.11; P = .03).

CONCLUSION:

Iliac artery aneurysmss can be safely and effectively treated by EVIR or OIR regarding 30-day morbidity, mortality, and long-term survival, although freedom from reintervention is significantly lower after EVIR.

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.

Type II endoleaks: diagnosis and treatment algorithm

Elective abdominal aortic aneurysm (AAA) repair is recommended for aneurysms greater than 5.5 cm, symptomatic, or rapidly expanding more than 0.5 cm in 6 months. Seventy-five percent of AAAs today are treated with endovascular aneurysm repair (EVAR) rather than open repair. This is fostered by the lower periprocedural mortality, complications, and length of hospital stay associated with EVAR. However, some studies have demonstrated EVAR to result in higher reintervention rates than with open repair, largely due to endoleaks. Type II is the most common, making up 10-25% of all endoleaks. Type II endoleaks, can potentially enlarge and pressurize the aneurysm sac with a risk of rupture. However, many type II endoleaks spontaneously resolve or never lead to sac enlargement. Imaging surveillance and approaches to management of type II endoleaks are reviewed here.

Open versus endovascular repair of ruptured abdominal aortic aneurysms: What have we learned after more than 2 decades of ruptured endovascular aneurysm repair?

BACKGROUND

Ruptured abdominal aortic aneurysm is one of the most difficult clinical problems in surgical practice, with extraordinarily high morbidity and mortality. During the past 23 years, the literature has become replete with reports regarding ruptured endovascular aneurysm repair.

METHODS

A variety of study designs and databases have been utilized to compare ruptured endovascular aneurysm repair and open surgical repair for ruptured abdominal aortic aneurysm and studies of various designs from different databases have yielded vastly different conclusions. It therefore remains controversial whether ruptured endovascular aneurysm repair improves outcomes after ruptured abdominal aortic aneurysm in comparison to open surgical repair.

RESULTS

The purpose of this article is to review the best available evidence comparing ruptured endovascular aneurysm repair and open surgical repair of ruptured abdominal aortic aneurysm, including single institution and multi-institutional retrospective observational studies, large national population-based studies, large national registries of prospectively collected data, and randomized controlled clinical trials.

CONCLUSION

This article will analyze the study designs and databases utilized with their attendant strengths and weaknesses to understand the sometimes vastly different conclusions the studies have reached. This article will attempt to integrate the data to distill some of the lessons that have been learned regarding ruptured endovascular aneurysm repair and identify ongoing needs in this field.

Surgical Versus Endovascular Aortic Aneurysm Repair: Evidence to Guide the Optimal Approach for the Individual Patient

The choice between an open surgical and an endovascular approach for abdominal aortic aneurysm (AAA) repair remains an individualized clinical decision. As the technology and applications of endovascular aortic aneurysm repair (EVAR) continue to evolve, so does the literature investigating its outcomes. Multiple high-quality, randomized controlled trials comparing EVAR to open surgical repair (OSR) have now been published with long-term follow-up. Experience with ruptured aneurysms and the use of complex endografts is growing as well. This review is an up-to-date compilation of pertinent clinical trials for practitioners placed in the context of individual patient considerations to guide the choice of an optimal approach to the management of AAAs.

Outcomes of endovascular and open surgical repair of ruptured abdominal aortic aneurysms in elderly patients

BACKGROUND

Endovascular aneurysm repair (EVAR) is becoming the preferred treatment modality for patients with a ruptured abdominal aortic aneurysm (rAAA). Although the survival advantage of EVAR over open aortic repair (OAR) has been shown in some studies, it is unclear whether this benefit extends to elderly patients. We sought to evaluate the outcomes of rAAA repair in octogenarians.

METHODS

We reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) data set (2005-2014) to identify patients older than 80 years who were treated with EVAR and OAR for rAAA. Procedural trends were evaluated during the course of the study period. Perioperative outcomes including mortality, morbidity, and hospital length of stay (LOS) were compared. Multivariable regression models were used to identify predictors of perioperative mortality and morbidity.

RESULTS

Among 1048 elderly patients who underwent rAAA repair, 450 (43%) and 598 (57%) were treated with EVAR and OAR, respectively. The use of EVAR to treat rAAA had increased significantly in this population of patients (0% in 2005 vs 56% in 2014; P < .001). The overall 30-day mortality rate among octogenarians was 41%. The mortality rate was significantly higher among those treated with OAR compared with EVAR (47% vs 33%; P < .001). Pneumonia (21% vs 10%; P < .001), reintubation (14% vs 9%; P < .001), and >48-hour ventilator dependence (43% vs 21%; P < .001) were significantly higher in patients undergoing OAR. Hospital LOS (13 vs 10 days; P < .001) was also longer in the OAR cohort. Compared with EVAR, OAR was independently predictive of 30-day mortality (adjusted odds ratio [AOR], 1.7; 95% confidence interval [CI], 1.3-2.2; P < .001), pneumonia (AOR, 2.4; 95% CI, 1.7-3.6; P < .001), >48-hour ventilator dependence (AOR, 2.5; 95% CI, 1.8-3.3; P < .001), and longer LOS (adjusted mean ratio, 1.4; 95% CI, 1.2-1.6; P < .001).

CONCLUSIONS

Elderly patients have significant but acceptable perioperative mortality and morbidity after rAAA repair. Use of endovascular repair in the elderly population has increased and is associated with better perioperative survival and 30-day outcomes compared with traditional open repair in this study.

The 100 most cited manuscripts in emergency abdominal surgery: A bibliometric analysis

BACKGROUND

The number of citations a scientific article receives provides a good indication of its impact within any given field. This bibliometric analysis aimed to identify the 100 most cited articles in Emergency Abdominal Surgery (EAS), to highlight key areas of interest and identify those that have most significantly shaped contemporary clinical practice in this newly evolving surgical specialty. This is of increasing relevance as concerns grow regarding the variable and suboptimal outcomes in Emergency General Surgery.

MATERIALS AND METHODS

The Thomson Reuters Web of Science database was used to search using the terms [Emergency AND Abdom* AND Surg*] to identify all English language, full manuscripts. Results were ranked according to citation number. The top 100 articles were further analysed by subject, author, journal, year of publication, institution, and country of origin.

RESULTS

The median (range) citation number of the top 100 out of 7433 eligible papers was 131 (1569-97). The most cited paper (by Goldman et al., Massachusetts General Hospital, New England Journal of Medicine; 1569 citations) focused on cardiac risk stratification in non-cardiac surgery. The Journal of Trauma, Injury, Infection and Critical Care published the most papers and received most citations (n = 19; 2954 citations. The majority of papers were published by centres in the USA (n = 52; 9422 citations), followed by the UK (n = 13; 1816 citations). The most common topics of publication concerned abdominal aneurysm management (n = 26) and emergency gastrointestinal surgery (n = 26).

CONCLUSION

Vascular surgery, risk assessment and gastrointestinal surgery were the areas of focus for 59% of the contemporary most cited emergency abdominal surgery manuscripts. By providing the most influential references this work serves as a guide to what makes a citable emergency surgery paper.

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.

Life-Saving Embolization in a Patient with Recurrent Shock Due to a Type II Endoleak after Endovascular Aortic Repair for a Ruptured Abdominal Aortic Aneurysm

A man in his 80s underwent urgent endovascular aortic repair (EVAR) for a ruptured abdominal aortic aneurysm (RAAA). Surgery was completed without apparent complications, and the patient was returned to the Cardiac Care Unit. Two hours later, he again developed shock, and contrast-enhanced Computed Tomography showed extravasation from a type II endoleak (T2EL) involving the IMA. Transcatheter arterial embolization (TAE) was immediately performed, and the patient's vital signs stabilized soon after embolization. Abdominal compartment syndrome was suspected during the procedure, so a retroperitoneal hematoma evacuation was performed. The patient's postoperative course was satisfactory, and he transferred to another hospital. EVAR for RAAA would be useful, but it is necessary to be considered that T2EL can cause the aggravation of unstable circulation.

Endovascular Repair of a Ruptured Pararenal Aortic Aneurysm Using the Nellix Endovascular Aneurysm Sealing System and Chimney Grafts

Purpose: To demonstrate the feasibility of emergent endovascular repair of a ruptured pararenal aneurysm using chimney grafts and the Nellix endovascular aneurysm sealing (EVAS) system to reduce the potential for endoleak from the gutters around the chimney grafts. Case Report: A 74-year-old patient presented with a ruptured pararenal aneurysm. Because of anatomical considerations after previous aortic surgery, conventional endovascular aneurysm repair was deemed impossible. It was decided to exclude the aneurysm with a Nellix EVAS system in conjunction with two chimneys to the renal arteries, even though this was outside the instructions for use of the device. Active bleeding was stopped directly after positioning the chimneys and filling the endobags with polymer. Completion angiography showed aneurysm exclusion and patent renal arteries. Renal function remained stable, and the patient was discharged at the third postoperative day. At 6 months, duplex ultrasound and computed tomography showed patent stents and chimneys and no evidence of endoleak. Conclusion: Using chimney grafts in combination with the Nellix endoprosthesis in a ruptured pararenal aneurysm is feasible. However, more robust data on both chimney-EVAS and EVAS in ruptured cases are required.