An intention-to-treat by endovascular repair policy may reduce overall mortality in ruptured abdominal aortic aneurysm

Systematic review and meta-analysis of the risk of bowel ischemia after ruptured abdominal aortic aneurysm repair

OBJECTIVE

Outcomes after repair of ruptured abdominal aortic aneurysm (RAAA) have improved in the last decade. It is unknown whether this has resulted in a reduction of postoperative bowel ischemia (BI). The primary objective was to determine BI prevalence after RAAA repair. Secondary objectives were to determine its major sequelae and differences between open repair (OR) and endovascular aneurysm repair (EVAR).

METHODS

This systematic review (PROSPERO CRD42017055920) followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Meta-analysis Of Observational Studies in Epidemiology (MOOSE) guidelines. MEDLINE and Embase were searched for studies published from 2005 until 2018. The methodologic quality of observational studies was assessed with the Methodological Index for Non-Randomized Studies (MINORS) tool. The quality of the randomized controlled trials (RCTs) was assessed with the Cochrane Collaboration's tool for assessing risk of bias. BI prevalence and rates of BI as cause of death, reoperation, and bowel resection were estimated with meta-analyses with a random-effects model. Differences between OR and EVAR were estimated with pooled risk ratios with 95% confidence intervals (CIs). Changes over time were assessed with Spearman rank test (ρ). Publication bias was assessed with a funnel plot analysis.

RESULTS

A total of 101 studies with 52,670 patients were included; 72 studies were retrospective cohort studies, 14 studies were prospective cohort studies, 12 studies were retrospective administrative database studies, and 3 studies were RCTs. The overall methodologic quality of the RCTs was high, but that of observational studies was low. The pooled prevalence of BI ranged from of 0.08 (95% CI, 0.07-0.09) in database studies to 0.10 (95% CI, 0.08-0.12) in cohort studies. The risk of BI was higher after OR than after EVAR (risk ratio, 1.79; 95% CI, 1.25-2.57). The pooled rate of BI as cause of death was 0.04 (95% CI, 0.03-0.05), and that of BI as cause of reoperation and bowel resection ranged between 0.05 and 0.07. BI prevalence did not change over time (ρ, -0.01; P = .93). The funnel plot analysis was highly suggestive of publication bias.

CONCLUSIONS

The prevalence of clinically relevant BI after RAAA repair is approximately 10%. Approximately 5% of patients undergoing RAAA repair suffer from severe consequences of BI. BI is less prevalent after EVAR than after OR.

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.

A 15-Year Single-Center Experience of Endovascular Repair for Elective and Ruptured Abdominal Aortic Aneurysms

Purpose: To evaluate the differences in technical outcomes and secondary interventions between elective endovascular aneurysm repair (el-EVAR) procedures and those for ruptured aneurysms (r-EVAR). Methods: Of the 906 patients treated with primary EVAR from September 1998 until July 2012, 43 cases were excluded owing to the use of first-generation stent-grafts. Among the remaining 863 patients, 773 (89.6%) patients (mean age 72 years; 697 men) with asymptomatic or symptomatic abdominal aortic aneurysms (AAAs) were assigned to the el-EVAR group; 90 (10.4%) patients (mean age 73 years; 73 men) were assigned to the r-EVAR group based on blood outside the aortic wall on preoperative imaging. The primary study outcome was technical success; secondary endpoints, including freedom from secondary interventions and late survival, were examined with Kaplan-Meier analyses. Results: At baseline, r-EVAR patients had larger aneurysms on average (p<0.001) compared to el-EVAR patients. Technical success was comparable (p=0.052), but there were more type Ia endoleaks at completion angiography in the r-EVAR group (p=0.038). As anticipated, more patients died in the first month in the r-EVAR group (18.9% vs 2.2% el-EVAR, p<0.001). At 5 years, there was an overall survival of 65.1% for the el-EVAR patients vs 48.1% in the r-EVAR group (p<0.001). The freedom from AAA-related mortality was 95.7% for el-EVAR and 71.0% for r-EVAR (p<0.001). Five-year freedom from type I/III endoleaks was significantly lower in the r-EVAR group (78.7% vs 90.0%, p=0.003). Five-year freedom from secondary intervention estimates were not significantly different (el-EVAR 84.2% vs r-EVAR 78.2%, p=0.064). Conclusion: Within our cohort of primary EVAR patients, r-EVAR cases showed comparable stent-graft–related technical outcome. Although there was a higher incidence of type Ia endoleaks on completion angiography in the r-EVAR group, the overall secondary intervention rate was comparable to el-EVAR.

Hypotensive Hemostatis (Permissive Hypotension) for Ruptured Abdominal Aortic Aneurysm: Are We Really in Control?

The purpose of this study was to investigate whether a protocol for permissive hypotension was feasible for patients admitted with a ruptured abdominal aortic aneurysm (RAAA). It was aimed to limit prehospital intravenous fluid administration to 500 mL and to maintain systolic blood pressure at a range of 50 to 100 mm Hg following admission, using nitrates when indicated. The diagnosis of RAAA was confirmed with sonography, and all patients with uncontrolled hypovolemic shock immediately underwent open aneurysm repair (OAR). In all other cases, computed tomographic (CT) angiography was performed to determine the eligibility for endovascular aneurysm repair (EVAR). From January 1, 2004, to December 31, 2006, 95 patients with a suspected RAAA were admitted. In 77 patients, the diagnosis of RAAA was confirmed. Twenty-eight cases (36%) underwent OAR for uncontrolled hemodynamic instability. Following CT-angiographic evaluation, 25 of the remaining 49 cases were considered unsuitable for EVAR and subsequently underwent OAR. In 24 of 77 cases (31%), the RAAA was treated with EVAR. Preoperative systolic blood pressure recordings in EVAR patients showed median values (± SD) of 98 (± 34.7) mm Hg in the emergency department and 114 (± 26.2) mm Hg in the operating theater. The desired systolic blood pressure range of 50 to 100 mm Hg was reached in 11 of 24 cases (46%). In 13 of 24 cases (54%), a systolic blood pressure higher than 100 mm Hg was recorded for a period longer than 60 minutes. The 30-day mortality was 32 of 77 (42%), with 6 of 24 (25%) in the EVAR group and 26 of 53 (49%) in the OAR group. This is the first published series of RAAA in which a protocol of permissive hypotension has been adopted. The concept appeared to be feasible in the majority of cases. Protocol violations were sparse ( n = 5). Uncontrolled hypotension occurred in 36% (28 of 77) of all patients, and the desired systolic blood pressure range was achieved in 46% (11 of 24) of the EVAR patients.

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.

A ruptured abdominal aortic aneurysm that requires preoperative cardiopulmonary resuscitation is not necessarily lethal

OBJECTIVE

A ruptured abdominal aortic aneurysm (RAAA) is associated with a high mortality rate. If cardiopulmonary resuscitation (CPR) is required before surgical repair, mortality rates are said to approach 100%. The aim of this multicenter, retrospective study was to study outcome in RAAA patients who required CPR before a surgical (endovascular or open) repair (CPR group). RAAA patients who did not need CPR served as controls (non-CPR group).

METHODS

Over a 5-year time period, demographic and clinical characteristics and specifics of preoperative CPR if necessary were studied in all patients who were treated for a RAAA in three large, nonacademic hospitals.

RESULTS

A total of 199 consecutive RAAA patients were available for analysis; 176 patients were surgically treated. Thirteen of these 176 patients (7.4%) needed CPR, and 163 (92.6%) did not. A 38.5% (5 of 13) survival rate was observed in the CPR group. Thirty-day mortality was almost three times greater in the CPR group compared with the non-CPR group (61.5% vs 22.7%; P = .005). Both CPR patients who received endovascular aortic repair survived. In contrast, survival in 11 CPR patients who underwent open RAAA repair was 27% (3 of 11; P = .128). A trend for higher Hardman index was found in patients who received CPR compared with patients who did not receive CPR (P = .052). The 30-day mortality in patients with a 0, 1, 2, or 3 Hardman index was 16.1%, 31.0%, 37.9%, and 33.3%, respectively (P = .093).

CONCLUSIONS

An RAAA that requires preoperative CPR is not necessarily a lethal combination. Patient selection must be tailored before surgery is denied.

EVAR for ruptured aneurysms: are the data complete?

Endovascular abdominal aneurysm repair is now the preferred therapy for many patients with abdominal aortic aneurysms and has been associated with reduced immediate and short-term morbidity and mortality. Because perioperative complications so often compromise the open repair of ruptured aortic aneurysms, EVAR has been considered as an attractive option in these patients. A number of small, typically single-center studies have demonstrated excellent results. In the absence of compelling, objective clinical data, there are certainly many patients with ruptured aortic aneurysms who are well-suited for EVAR. The development of protocols and systems for the expeditious diagnosis and treatment of ruptured aneurysms should further improve therapy for this life-threatening condition.

A case of hybrid repair of ruptured abdominal aortic aneurysm with use of thrombin for acute treatment of type II endoleak

Endovascular repair for ruptured abdominal aortic aneurysm has demonstrated superior results when compared with open repair and will likely become the standard of care when the anatomy of the aneurysm is appropriate for endovascular repair.

Population-based outcomes following endovascular and open repair of ruptured abdominal aortic aneurysms

PURPOSE

To evaluate national outcomes after endovascular and open surgical repair of ruptured abdominal aortic aneurysms (rAAA).

METHODS

The Nationwide Inpatient Sample was interrogated to identify all repairs between 2000 and 2005 for rAAA based on ICD-9 codes. In the study period, 2323 patients (1794 men; median age 75 years, range 45-98) with rAAAs had endovascular repair, while 26,106 patients (20,311 men; median age 73 years, range 22-99) had an open procedure. Outcomes included in-hospital mortality, length of stay (LOS), complications, and hospitalization charge. A secondary analysis was performed to compare outcomes from low-, medium-, and high-volume institutions based on annual rAAA repair volume.

RESULTS

Patients in the endovascular group were significantly older (p<0.05). Mortality was 41% overall: 33% and 41% for endovascular versus open repair, respectively (p<0.001). Mortality after endovascular repair was lower than open surgery for patients >or=70 years (36% versus 47%, p<0.001), but not for those <70 years (24% versus 30%, p = 0.15). LOS was shorter after endovascular repair (7 versus 9 days, p<0.001). Respiratory complications (8% versus 4%, p<0.05) and acute renal failure were more common following open repair (30% versus 23%, p<0.01). Costs were similar (endo $73,590 versus open $67,287, p = 0.15). Mortality decreased as hospital surgical volume increased (low 44%, medium 39%, high 38%; p<0.001). Over time, endovascular repair utilization increased more rapidly at high-volume centers, and a lower mortality was seen with endovascular repair at high-volume compared to low-volume hospitals (22% versus 44%, p<0.001). Multivariate predictors of mortality were age, female gender, lower hospital surgical volume, open repair, and year of surgery.

CONCLUSION

This population-based study found that mortality associated with rAAAs may be improved by the performance of endovascular repair, especially in older patients. Mortality after rAAA for both endovascular and open repairs was also lower at high-volume institutions.

Comparison of open and endovascular repair of ruptured abdominal aortic aneurysms from the ACS-NSQIP 2005-07

PURPOSE

To compare endovascular (EVAR) and open surgical repair (OSR) for ruptured abdominal aortic aneurysms (RAAA) in terms of preoperative hemodynamic status and comorbidities.

METHODS

The 2005 to 2007 American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was interrogated to find all patients undergoing repair for RAAA. Of the 567 RAAA repairs identified, 121 (21%) were endovascular and 446 (79%) were open. Demographics, comorbidities, and preoperative hemodynamic status were compared by repair method.

RESULTS

Age, sex, and race were similar between repair cohorts. EVAR patients had greater incidences of recent myocardial infarction (7% versus 2%, p<0.05), revascularization or amputation for peripheral vascular disease (8% versus 3%, p<0.05), and cerebrovascular disease (22% versus 11%, p<0.01). Preoperative hemodynamic status was similar based on need for >4 units of blood (3% versus 6%, p = 0.31), intubation (12% versus 17%, p = 0.18), impaired sensorium (7% versus 11%, p = 0.25), coma (4% versus 5%, p = 0.65), acute renal failure (2% versus 2%, p = 0.60), and ASA class 5 (29% versus 34%, p = 0.29). Open repair was associated with greater operative time (3.3 versus 2.6 hours, p<0.01) and intraoperative blood transfusions (8 versus 2 units, p<0.001). Overall mortality was 33.5% (EVAR 24% versus OSR 36%; OR 1.8, 95% CI 1.1 to 2.8, p<0.05). After adjusting for preoperative comorbidities and all preoperative hemodynamic variables, mortality after open repair was greater than after EVAR (OR 1.9, 95% CI 1.1 to 3.2, p<0.05). Overall postoperative complications were greater after open repair (62% versus 47%, p<0.01). Graft failure requiring reintervention was higher after EVAR (4% versus 1%, p<0.05), while rates of return to the operating room for a major operation were similar (21% versus 24%, p = 0.43).

CONCLUSION

For RAAA within NSQIP hospitals in recent years, preoperative hemodynamic status was similar between EVAR and OSR, but EVAR patients had greater comorbidities. Despite this and after accounting for minor differences in hemodynamic status, EVAR mortality was lower than OSR mortality. Institutions with adequate experience and resources should attempt endovascular repair for RAAA when anatomy allows.

Ruptured abdominal aortic aneurysms in southern Saskatchewan: a 10-year mortality review

The Regina Qu'Appelle Health Region (RQHR) provides all tertiary vascular care for southern Saskatchewan and portions of southwestern Manitoba. The present study was undertaken to determine the regional mortality rates following rupture of an abdominal aortic aneurysm and to compare these rates with the published literature. A retrospective chart review was undertaken on all cases of ruptured abdominal aortic aneurysms (rAAA) presenting to the RQHR between March 1, 1996, and February 28, 2006. The demographic data and clinical outcomes were collected from hospital charts by a single reviewer. Over the 10-year study period, 101 cases of rAAA were presented to the RQHR. Patient demographics and comorbidities were comparable to other studies in the published literature. Thirty-seven percent of patients presented with systolic blood pressure below 90 mm Hg, and 7% had no recordable blood pressure. The overall mortality was 25%. Mortality risk was not statistically different between patients presenting within Regina (30%) and those referred from a distance of more than 35 km (21%, P = .353). Seven patients were treated palliatively, and 94 proceeded to open surgical repair. Within the group of patients undergoing surgery, there was a 19% mortality rate. The data show a low observed mortality rate for rAAA presenting to the RQHR. The favorable outcome of the patients is not associated with preselection bias of patients transported long distances to specialist vascular care.

Endovascular Repair of Ruptured Abdominal Aortic Aneurysms: Systematic Literature Review

Endovascular repair is increasingly used for ruptured abdominal aortic aneurysms (RAAAs). This study estimated the mortality rate for this approach. A review of 307 publications in English was performed. Thirty-four publications representing 1,200 patients with RAAA were deemed appropriate for analysis by weighted least squares regression. Of the 1,200 patients, 531 (44.3%) underwent endovascular aneurysm repair (EVAR). The average age was 74 years, and 13% were female. Aortouni-iliac grafts were used in 49.4% of patients, and 50.6% received bifurcated grafts. The technical success rate was 94.9%, with a mortality rate of 30.2%. The ratio of endovascular cases to the total number of cases strongly predicted the mortality rate (weighted coefficient −0.378, p < .0003). The mortality rate following EVAR of RAAA is 30%. A 3.8% reduction in mortality was found for each 10% increase in the percentage of ruptures repaired endovascularly at each center. These results are suggestive of a learning curve.

Endovascular Repair of the Ruptured Abdominal Aortic Aneurysm

The present knowledge on endovascular repair of ruptured abdominal aortic aneurysms (rAAA) prevents firm conclusions when to use this method in comparison to open repair. This review article briefly summarizes results from case series, and discusses how to achieve reliable information despite the absence of randomized controlled trials. At present a careful conclusion might be that dedicated centers with an adequate organization and reasonably high volume of abdominal aortic aneurysm (AAA) should use detailed registry protocols to achieve experience and data to create an as reliable basis as possible for future recommendations.

Early and mid-term results of ruptured abdominal aortic aneurysms in the endovascular era in a community hospital

OBJECTIVE

Endovascular repair (EVAR) has been increasingly used for ruptured abdominal aortic aneurysms (rAAAs), especially in major academic centers. The goal of this article is to report our results with an EVAR-first approach for rAAA which we adopted in 2001 in our community hospital.

METHODS

All consecutive patients who underwent attempted repair for rAAA between February 2001 and July 2006 were analyzed. Only patients with computed tomographic or visual verification of extraluminal blood were included.

RESULTS

A total of 40 patients (30 men; mean age, 76.4 +/- 7.2 years; range, 57-89 years) presented with rAAA. Thirty patients underwent attempted EVAR for rAAA, constituting 4.1% of all EVAR cases (n = 738), and 10 patients had attempted open repair. Twenty-one (53%) were transferred from another institution. Computed tomography was performed in 97.5%. On arrival to the emergency department, 43%% were hypotensive (systolic blood pressure <80 mm Hg). Transfemoral balloon occlusion was used in 12 cases (30%; 10 in the EVAR group and 2 in the open group). The length of operation was 128 +/- 35 minutes (range, 77-210 minutes) in EVAR cases. EVAR was completed in 93.3% (iliac anatomy and proximal endoleak caused open conversion in two cases). Out of the 10 open treated cases, 1 was converted to EVAR and survived. The grafts used for EVAR were AneuRx (n = 21), Zenith (n = 5), and Ancure (n = 4), and 97% were bifurcated. Five patients (16.6%) in the EVAR group died within 30 days (four required balloon occlusion). The mean length of stay was 9.1 +/- 6.2 days (range, 4-30 days) in survivors of EVAR. In the EVAR-treated group, two patients died (7 and 9 months; unrelated), and six of the surviving patients (23%) required secondary procedures (five femorofemoral bypasses for limb occlusions and one proximal cuff for a type I endoleak that caused repeat rupture) during a mean follow-up of 13.8 +/- 10.4 months (range, 3-39 months). The mortality rate was 40% (4/10) in patients who underwent open procedures during this period, with an overall mortality rate of 22.5% for all ruptures treated. The difference in 30-day mortality in the EVAR and open groups did not reach statistical significance (17% vs 40%; P = .19). In the entire cohort, hypotension (systolic blood pressure <80 mm Hg) on arrival and loss of consciousness were associated with 30-day mortality. Balloon occlusion was correlated with mortality in the EVAR-treated group (44% vs 4%; P = .019). The multivariate analysis using logistic regression showed that hypotension (odds ratio [OR], 7.4; 95% confidence interval [CI], 1.3-42.0; P = .025), loss of consciousness (OR, 37.5; 95% CI, 3.4-40.8; P = .003), and the need for balloon occlusion (OR, 5.2; 95% CI, 1.8-25.5; P = .042) were correlated with higher perioperative mortality, whereas age greater than 76 years, coronary artery disease, chronic obstructive pulmonary disease, hypertension, diabetes, renal insufficiency, and type of procedure did not.

CONCLUSIONS

Our results show that EVAR is feasible with favorable outcomes in patients presenting with rAAA in a busy community hospital. There is a high secondary intervention rate, which can potentially be decreased by ensuring good iliac limb anatomy at the end of the procedure and by a closer follow-up.

Endovascular Ruptured Abdominal Aortic Aneurysm Repair (EVRAR): A Systematic Review

BACKGROUND

To review evidence supporting the use of endovascular ruptured aneurysm repair (EVRAR) for treatment of ruptured abdominal aortic aneurysm (RAAA).

METHODS

A systematic review of the medical literature was performed for relevant studies. We searched a number of electronic databases and hand-searched relevant journals until November 2006 to identify studies for inclusion. We considered studies in which patients with a confirmed ruptured abdominal aortic aneurysm were treated with EVRAR, which reported endpoints of mortality and major complications.

RESULTS

There was 1 randomised controlled trial (RCT), 33 non-randomised case series (24 retrospective and 9 prospective) reports were identified comparing EVRAR (n=891) with conventional open surgical repair for the treatment of RAAA. Whilst no benefit in the primary outcome of mortality was noted in the only RCT, evidence from non-randomised studies suggest that EVRAR is feasible in selected patients, where it may be associated with a trend towards reductions in blood loss, duration of intensive care treatment, early complications, and mortality.

CONCLUSIONS

For the treatment of symptomatic or ruptured abdominal aortic aneurysm, emergency endovascular repair (EVRAR) is feasible in selected patients, with early outcomes comparable to best conventional open surgical repair for the treatment of RAAA.

Endovascular Repair of Ruptured Abdominal Aortic Aneurysms: Experience in a Community Hospital

The endovascular technique has been recently used as an alternative procedure for selected patients with ruptured abdominal aortic aneurysm (RAAA) as a result of the potential for decreasing morbidity, mortality, and recovery time. We examined our institution's results with endovascular repair of RAAA. Between July 2005 and April 2006, four patients underwent endovascular repair of infrarenal RAAA. We performed a retrospective analysis of our comorbidities, operation time, length of intensive care unit and hospital stay, morbidity and mortality, blood transfusions, and secondary interventions on these patients at our institution. The median age was 73.2 years (range, 66–82 years); 75 per cent were male and 25 per cent were female. Mean operating time was 90 minutes. We had no operative or postoperative mortalities. Five complications occurred in three patients. These included acute renal failure, common femoral artery intimal dissection, graft thrombosis of the iliac limb, ischemic colitis, and chronic obstructive pulmonary disease exacerbation. Endovascular repair of RAAA by an endovascular team is feasible in the community hospital setting. Our limited number of patients in this study does not allow us to compare it directly with results from the standard open procedure. A larger, multi-center study may eventually show this method to be helpful in patients who require repair of RAAA.

Improved survival after introduction of an emergency endovascular therapy protocol for ruptured abdominal aortic aneurysms

BACKGROUND

The study was conducted to demonstrate improved survival (30-day mortality) after the introduction of an emergency endovascular therapy protocol for ruptured abdominal aortic aneurysms (rAAA). Numerous authors have successfully demonstrated reduced mortality in patients with rAAA using endovascular techniques. Comparison of endovascular aneurysm repair (EVAR) with open repair for rAAA may be misleading, however, because EVAR cannot be performed on all patients, and selection bias may explain the superior performance of any given surgical or endovascular strategy. We developed a model to predict mortality in patients before the introduction of EVAR (preprotocol population), applied this model to predict 30-day mortality among prospective patients (postprotocol population), and compared observed vs expected results.

METHODS

We assessed 126 patients with rAAA. Primary outcome was 30-day mortality. Potential confounding variables were age, sex, presurgical lowest recorded systolic blood pressure (SBP), and glomerular filtration rate (GFR). A logistic regression model incorporating significant confounders was used to evaluate changes in 30-day mortality for all patients with rAAA after introduction of the EVAR protocol. Separate logistic regressions were done to compare 30-day mortality for preprotocol vs patients receiving EVAR and preprotocol vs patients receiving postprotocol open repair. Cumulative sum (CUSUM) analysis was used to assess shifts in the performance of the rAAA program over time.

RESULTS

Significant confounders were SBP, absence of SBP, and GFR. Logistic regression found evidence of lower mortality after the protocol was introduced, 17.9% vs 30.0% (odds ratio [OR], 0.385; 95% confidence interval [CI], 0.141 to 0.981; P = .046). Comparison of all open repairs (preprotocol and postprotocol) and EVAR demonstrated decreased risk for EVAR of 5.0% vs 28.3% (OR, 0.109; 95% CI, 0.013 to 0.906; P = .0084). Unstable patients (SBP <or=80) showed a trend towards improved survival with EVAR relative to open repair (14.3% vs 56.0%, P = .061). Comparison of preprotocol surgery with open repair after the introduction of the protocol found no evidence of a difference between mortality rates for the open procedures-30.0% (preprotocol) vs 25.0% (postprotocol; OR, 0.688; 95% CI, 0.335 to 1.415, P = .3031)-demonstrating that the improved performance observed with CUSUM analysis was related to the introduction of the EVAR protocol.

CONCLUSION

Our predictive model using "weighted" CUSUM analysis (a measure of performance over time) demonstrated that a predefined strategy of management of rAAA that includes EVAR is associated with improved (P < .05) mortality. Unstable patients with rAAA may be particularly benefited by EVAR and should not be excluded from repair. Appropriate patients with rAAA who are undergoing treatment in experienced vascular centers should be offered EVAR as the treatment of choice.