A single-center experience in open and endovascular treatment of hemodynamically unstable and stable patients with ruptured abdominal aortic aneurysms

Evaluation of national institute for health and care excellence guidance for ruptured abdominal aortic aneurysms by emulating a hypothetical target trial

Objective

This retrospective study evaluates the performance of UK National Institute for Health and Care Excellence (NICE) Guidelines on management of ruptured abdominal aortic aneurysms in a "real world setting" by emulating a hypothetical target trial with data from two European Aortic Centers.

Methods

Clinical data was retrospectively collected for all patients who had undergone ruptured endovascular aneurysm repair (rEVAR) and ruptured open surgical repair (rOSR). Survival analysis was performed comparing NICE compliance to usual care strategy. NICE compliers were defined as: female patients undergoing rEVAR; male patients >70 years old undergoing rEVAR; and male patients ≤70 years old undergoing rOSR. Hemodynamic instability was considered additionally.

Results

This multicenter study included 298 patients treated for rAAA. The majority of patients were treated with rOSR (186 rOSR vs. 112 rEVAR). Overall, 184 deaths (68 [37%] with rEVAR and 116 [63%] with rOSR) were observed during the study period. Overall survival under usual care was 69.2% at 30 days, 56.5% at one year, and 42.4% at 5 years. NICE compliance gave survival outcomes of 73.1% at 30 days, 60.2% at 1 year and 42.9% at 5 years. The risk ratios at these time points, comparing NICE-compliance to usual care, were 0.88, 0.92 and 0.99, respectively.

Conclusions

We support NICE recommendations to manage men below the age of 71 years and hemodynamic stability with rOSR. There was a slight survival advantage for NICE compliers overall, in men >70 years and women of all ages.

Detection of Ischemic Colitis on Routine Lower Endoscopy and Its Implications After Repair of Ruptured Abdominal Aortic Aneurysm

BACKGROUND

Ischemic colitis (IC) is a known significant complication after repair of a ruptured abdominal aortic aneurysm (rAAA). Lower endoscopy (colonoscopy or flexible sigmoidoscopy) is a helpful adjunct to aid decision making for surgical exploration. We believe routine use of lower endoscopy after rAAA repair provides better patient care through expeditious diagnosis and surgical care.

METHODS

We performed a retrospective chart review of rAAA repairs from 2008 to 2019. All patients undergo screening lower endoscopy after rAAA repair at our institution. The incidence of IC, mortality, and diagnostic characteristics of routine lower endoscopy was analyzed.

RESULTS

Of these, 182 patients underwent rAAA repair, among which 139 (76%) underwent routine lower endoscopy. Ischemic colitis of any grade was diagnosed in 25% of patients. The 30-day mortality was 11% compared to 19% in those without lower endoscopy. The presence of IC portended a 4-fold increase in mortality rate compared to those without (26% vs 6%, P = .005). Surgical exploration rate was 8% after routine lower endoscopy. Grade III ischemia on lower endoscopy had a sensitivity of 50% (95% CI 12-88) and specificity of 99% (95% CI 94-100) for transmural necrosis.

DISCUSSION

We found increased incidence of IC and reliable diagnostic characteristics of routine lower endoscopy in predicting the presence of transmural colonic ischemia. There was decreased mortality with use of routine lower endoscopy but this was not statistically significant.

Outcomes and predictors of mortality in a Belgian population of patients admitted with ruptured abdominal aortic aneurysm and treated by open repair in the contemporary era

BACKGROUND

Abdominal aortic aneurysm (AAA) rupture is a serious condition that results in extremely high mortality rates. Some improvements in outcome have been reported during the last 2 decades. The objective of the present study was to determine the overall and operative (by open repair) mortality related to ruptured AAA in the contemporary era and to identify preoperative, intraoperative, and early postoperative parameters associated with poor outcomes.

METHODS

We performed a retrospective review of all consecutive patients admitted to our single institution with a diagnosis of ruptured AAA between 2004 and 2013. A total of 103 parameters, including demographic characteristics, medical history, clinical and biological parameters, cardiovascular risk factors, emergency level, diagnostic modalities, time from symptoms to diagnosis and treatment, type of operative procedure and postoperative complications, were analyzed. The primary endpoint considered in this study was the cumulative incidence rate of mortality. The secondary endpoint was the identification, by logistic regression methods, of risk factors for overall mortality as well as for operative, and postoperative mortality.

RESULTS

Within our study period, 104 patients were admitted for a ruptured AAA. The majority of patients (84.6%) were male, and the AAA was known in 34.6% of the patients. Rupture occurred for a maximal diameter lower than 55 mm in 25% of the female population, compared to 5.7% of the male population (P = 0.030). The proportions of admitted patients who died before (preoperative mortality), during (intraoperative mortality) or after (postoperative hospital mortality) surgery was 17.3%, 16.3%, and 18.3%, respectively, yielding a cumulative in-hospital mortality of 51.9%. In the multivariate analysis, age ≥ 80 (P = 0.001), myocardial ischemia on the admission ECG (P = 0.046), and management by the physician response unit (P = 0.002) were the only preoperative parameters associated with a higher risk of hospital mortality. Four risk factors were found to be associated with a higher risk of postoperative mortality in the multivariate analysis, and all patients presenting with 3 or more of these risk factors (n = 5) died.

CONCLUSIONS

The overall mortality of ruptured AAA in a contemporary cohort of patients who underwent open repair remains high and does not seem to have decreased during recent decades. Ruptures occur at smaller diameters in women than in men, supporting a lower threshold for intervention in women with known AAA. We developed risk scores to predict the mortality of patients with rAAA at different times of their hospital course. The validity of these scores should be assessed in prospective clinical studies.

A Case Report on Endovascular Aortic Repair Rupture

Endovascular repair of an abdominal aortic aneurysm (AAA) is a widely accepted alternative to open surgical AAA repair. A ruptured AAA is among the emergency surgeries with the highest risk of death, with an overall mortality rate close to90%. However, the classic symptom triad for ruptured AAAs of hypotension, a pulsatile mass, and abdominal/back pain is seen in only in 25% to 50% of affected patients. Thus, many present with symptoms and signs that suggest adifferent diagnosis. Recognizing uncommon presentations and limitations of imaging and interpretation, in addition to clinical gestalt, can save many lives. This report discusses an unusual case involving a previously repaired AAA presenting with acute rupture at the endograft site.

Inverse probability of treatment analysis of open vs endovascular repair in ruptured infrarenal aortic aneurysm - Cohort study

BACKGROUND

To compare open repair (OR) with EVAR for the management of ruptured infrarenal abdominal aortic aneurysms (RAAA) in a cohort study over a time period of 15 years with inverse probability of treatment weights.

MATERIAL AND METHODS

From 2000/01 through 2015/12 136 patients were treated for RAAA, 98 (72.1%) underwent OR, 38 (27.9%) were treated with EVAR. Thirty-day and long-term mortality (survival) were analyzed in this IRB-approved retrospective cohort study. Treatment modalities were compared using inverse probability of treatment weights to adjust for imbalances in demographic data and risk factors.

RESULTS

EVAR patients were older (75.11 ± 7.17 vs 69.79 ± 10.24; p=0.001). There was no statistical difference in gender, hypertension, COPD, CAD, or diabetes. GFR was significantly higher in OR patients (71.4 ± 31.09 vs. 53.68 ± 25.73). Postoperative dialysis was required more frequently in EVAR patients: 11% vs. 2% (p = 0.099). In the OR group, adjusted cumulative survival was 70.4% (61.1, 81.1) at 30 days, 47.0% (37.1, 59.6) at one year and 38.3% (28.6, 51.3) at 5 years. In the EVAR group the corresponding numbers were 77.0% (67.7, 87.5), 67.5% (57.0, 80.0) and 41.7% (30.4, 57.4), respectively.

CONCLUSION

There is evidence for EVAR patients exhibiting a benefit in one-year survival, while patients treated with OR may have more favorable long-term survival given they survive for at least one year. Herein we provide a statistically rigorous comparison of OR and EVAR in short and long-term outcomes with up to 15 years of follow-up.

Abdominal compartment syndrome after r-EVAR: a systematic review with meta-analysis on incidence and mortality

INTRODUCTION

Endovascular aneurysm repair for ruptured abdominal aortic aneurysms (r-EVAR) sometimes complicates with abdominal compartment syndrome (ACS) due to extensive retroperitoneal hematoma, with significant prognostic implications. This systematic review aimed to analyze the incidence of the syndrome and assess the impact of ACS on mortality. Mortality after decompressive laparotomy was also assessed.

EVIDENCE ACQUISITION

Two databases were searched: Medline and Web of Science. The search was conducted through October 2019. The titles and abstracts of the retrieved articles were independently reviewed. All studies reporting on the ACS incidence after r-EVAR were initially included. From each study, eligibility was determined and descriptive, methodological, and outcome data was extracted. The incidence was calculated with summary proportion. Odds ratio was used to compare the mortality rate. Meta-analysis was performed with fixed effect model when calculating the ACS incidence in r-EVAR patients and when assessing the impacts of ACS and DL in the mortality rate.

EVIDENCE SYNTHESIS

A total of 46 studies were included, with a cumulative cohort of 3064 patients. Two hundred and fifty-two (8.2%) patients developed ACS. The ACS pooled incidence was 9% with a 95% confidence interval of [0.08; 0.11]. Among the 46 included studies, 19 studies reported data on the mortality rate, corresponding to 1825 of the 3064 patients. Of these, 169 (9.3%) had developed ACS and 94 (55.6%) of them died by multi organ failure. Among the 1656 patients without ACS, 328 died (19.8%). The mortality odds ratio meta-analysis was 6.25 with a 95% confidence interval of [4.44, 8.80]. Decompressive laparotomy was performed in 41 patients, decreasing mortality in 47%.

CONCLUSIONS

ACS affects approximately 9% of patients submitted to r-EVAR, and significantly increases perioperative mortality. Close postoperative surveillance to clinical signs of ACS is vital in these patients.

[Colonic ischemia after open and endovascular aortic surgery : Epidemiology, Risk Factors, Diagnosis And Therapy]

Despite the successful establishment of endovascular techniques, colonic ischemia continues to be a serious complication of aortic surgery.The risk factors for colonic ischemia include aortic aneurysm rupture, prolonged aortic clamping, perioperative hypotension, the need for catecholamine therapy, occlusion of the hypogastric arteries and renal insufficiency.The clinical presentation of postoperative colonic ischemia is often unspecific. Classic symptoms include abdominal pain, diarrhea, peranal bleeding and rise of inflammatory parameters. A specific laboratory parameter for colonic ischemia does not exist. The diagnostic gold standard is endoscopy. Imaging methods such as sonography or computer tomography play only a supportive role. Transmural ischemia resulting in bowel wall necrosis is an indication for emergency surgery, predominantly colonic resection with creation of artificial anus.

Endovascular aneurysm sealing with the Nellix endograft in hemodynamically-unstable ruptured abdominal aortic aneurysm with challenging anatomy

BACKGROUND

To assess immediate and midterm outcomes of hemodynamically-unstable patients with ruptured abdominal aortic aneurysm (rAAA) treated with the Nellix endovascular sealing system (EVAS).

METHODS

From June 2014 to June 2017, 21 hemodynamically-unstable rAAA patients with challenging anatomies were treated with EVAS. The mean AAA diameter and neck length measured 73±15 mm and 14±10 mm, respectively. All the patients presented an advance trauma life support (ATLS) hemorrhage class ≥1 confirming a compromised hemodynamic status. Primary endpoints include technical success, treatment success, primary safety and 30-day survival. Secondary endpoints include re-intervention rate and time free-from-reintervention.

RESULTS

Technical success was achieved in 95% (N.=20/21); one patient was converted intraoperatively to open surgery due to ongoing hemorrhage. Seven re-interventions were performed within 30-days and one during the follow-up; treatment success rate of 67% and re-intervention rate of 33%. Early endoleaks were diagnosed in 5 patients (24%). Primary safety was 52%. After a mean follow-up of 11±10 months, survival rates were 81%, 62% and 57% at 1, 6 and 12 months, respectively. Time free-from-reintervention was 15±11 months.

CONCLUSIONS

Emergency-EVAS (eEVAS) appeared feasible and useful, especially in hemodynamically-unstable patients with challenging anatomies. There are some limitations in this cohort study and larger, prospective and comparative studies are required to confirm eEVAS as part of an emergency treatment protocol for rAAA.

A systematic review and meta-analysis of the use of resuscitative endovascular balloon occlusion of the aorta in the management of major exsanguination

BACKGROUND

Circulatory collapse is a leading cause of mortality among traumatic major exsanguination and in ruptured aortic aneurysm patients. Approximately 40% of patients die before hemorrhage control is achieved. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an adjunct designed to sustain the circulation until definitive surgical or endovascular repair. A systematic review was conducted for the current clinical use of REBOA in patients with hemodynamic instability and to discuss its potential role in improving prehospital and in-hospital outcome.

METHODS

Systematic review and meta-analysis (1900-2017) using MEDLINE, Cochrane, EMBASE, Web of Science and Central and Emcare using the keywords "aortic balloon occlusion", "aortic balloon tamponade", "REBOA", and "Resuscitative Endovascular Balloon Occlusion" in combination with hemorrhage control, hemorrhage, resuscitation, shock, ruptured abdominal or thoracic aorta, endovascular repair, and open repair. Original published studies on human subjects were considered.

RESULTS

A total of 490 studies were identified; 89 met criteria for inclusion. Of the 1436 patients, overall reported mortality was 49.2% (613/1246) with significant differences (p < 0.001) between clinical indications. Hemodynamic shock was evident in 79.3%, values between clinical indications showed significant difference (p < 0.001). REBOA was favored as treatment in trauma patients in terms of mortality. Pooled analysis demonstrated an increase in mean systolic pressure by almost 50 mmHg following REBOA use.

CONCLUSION

REBOA has been used in trauma patients and ruptured aortic aneurysm patients with improvement of hemodynamic parameters and outcomes for several decades. Formal, prospective study is warranted to clarify the role of this adjunct in all hemodynamic unstable patients.

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.

Endovascular repair versus open surgery in patients in the treatment of the ruptured of aneurysms abdominal

INTRODUCTION

Rupture of abdominal aortic aneurysm is still a difficult challenge for the vascular surgeon due to the high perioperative mortality. The aim of our study is to describe the characteristics of the population as well as to compare morbidity and mortality in patients undergoing open surgery or endovascular repair in our center.

METHODS

Database with 82 rAAA between January 2002-December 2014, studying two cohorts, open surgery and endovascular repair. Epidemiologic, clinical, surgical techniques, perioperative mortality and complications are analyzed.

RESULTS

82 rAAA cases were operated (men: 80, women: 2). Mean age 72±9.6 years. 76.8% (63 cases) was performed by open surgery.

BACKGROUND

smokers 59, 7%, alcoholism 19.5%, DM 10.9%, AHT: 53.6%, dyslipidemia 30.5%. The most frequent clinical presentation was abdominal pain with lumbar irradiation: 50 cases (20.7% associating syncope). Overall hospital mortality was 58.5%. Hemodynamic shock prior to intervention was associated with increased mortality (p <.001). Anemia, leukocytosis, aneurysm size, sex and age did not show a statistically significant difference with respect to mortality (p>.05). The presence of iliac aneurysms was associated with increased mortality (p <.0045). Perioperative mortality in endovascular repair was 42%, and in open surgery was 63.5% (p>.05). Hospital stay was lower in the endovascular group (p=.3859).

CONCLUSIONS

Hemodynamic shock and the presence of concomitant iliac aneurysms have a statistically significant association with perioperative mortality in both groups. We found clinically significant differences in mortality, complications and hospital stay when comparing both groups with better results for EVAR, without statistically significant differences.

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.

Risk factors for ischaemic colitis after surgery for abdominal aortic aneurysm: a systematic review and observational meta-analysis

BACKGROUND

Ischaemic colitis is an infrequent but serious complication following repair of abdominal aortic aneurysm (AAA), with high mortality rates. This systematic review set out to identify risk factors for the development of ischaemic colitis after AAA surgery.

METHODS

A systematic search of the MEDLINE, EMBASE and CINAHL databases was performed. This search was limited to studies published in the English language after 1990. Abstracts were screened by two authors. Eligible studies were obtained as full text for further examination. Data was extracted by two authors, and any disputes were resolved via consensus. Extracted data was pooled using Mantel-Haenszel random effects models. Bias was assessed using two Cochrane-approved tools. Effect sizes are expressed as relative risk ratios alongside the 95 % confidence interval. Statistical significance was defined at the level of p < 0.05.

RESULTS

From 388 studies identified in the initial search, 33 articles were included in the final synthesis and analysis. Risk factors were grouped into patient (female gender, disease severity) and operative factors (peri-procedural hypotension, operative modality). The risk of ischaemic colitis was significantly higher when undergoing emergency repair versus elective (risk ratio (RR) 7.36, 3.08 to 17.58, p < 0.001). Endovascular repair reduced the likelihood of ischaemic colitis (RR 0.22, 0.12 to 0.39, p < 0.001).

DISCUSSION

The quality of published evidence on this subject is poor with many retrospective datasets and inconsistent reporting across studies. Despite this, emergency presentation and open repair should prompt close monitoring for the development of IC.

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.

WSES position paper on vascular emergency surgery

Trauma, both blunt and penetrating, is extremely common worldwide, as trauma to major vessels. The management of these patients requires specialized surgical skills and techniques of the trauma surgeon. Furthermore few other surgical emergencies require immediate diagnosis and treatment like a ruptured abdominal aortic aneurysm (rAAA). Mortality of patients with a rAAA reaches 85 %, with more than half dying before reaching the hospital. These are acute events demanding immediate intervention to save life and limb and precluding any attempt at transfer or referral. It is the purpose of this position paper to discuss neck, chest, extremities and abdominal trauma, bringing to light recent evidence based data as well as expert opinions; besides, in this paper we present a review of the recent literature on rAAA and we discuss the rationale for transfer to referral center, the role of preoperative imaging and the pros and cons of Endoluminal repair of rAAA (REVAR) versus Open Repair (OR).

General considerations of ruptured abdominal aortic aneurysm: ruptured abdominal aortic aneurysm

Although development of surgical technique and critical care, ruptured abdominal aortic aneurysm still carries a high mortality. In order to obtain good results, various efforts have been attempted. This paper reviews initial management of ruptured abdominal aortic aneurysm and discuss the key point open surgical repair and endovascular aneurysm repair.

Open versus Endovascular Repair of Abdominal Aortic Aneurysm in the Elective and Emergent Setting in a Pooled Population of 37,781 Patients: A Systematic Review and Meta-Analysis

Background. We evaluated the incidence of mortality and myocardial infarction (MI) in endovascular repair (EVAR) as compared to open aneurysm repair (OAR) in both elective and ruptured abdominal aortic aneurysm (AAA ) setting. Methods. We analyzed the rates of 30-day mortality, 30-day MI, and hospital length of stay (LOS) based on comparative observation and randomized control trials involving EVAR and OAR. Results. 41 trials compared EVAR to OAR with a total pooled population of 37,781 patients. Analysis of elective and ruptured AAA repair favored EVAR with respect to 30-day mortality with a pooled odds ratio of 0.19 (95% CI 0.17–0.20; I² = 88.9%; P < 0.001). There were a total of 1,835 30-day MI events reported in the EVAR group as compared to 2,483 events in the OAR group. The pooled odds ratio for elective AAA was 0.74 (95% CI 0.58–0.96; P = 0.02) in favor of EVAR. The average LOS was reduced by 296.75 hrs (95% CI 156.68–436.82 hrs; P < 0.001) in the EVAR population. Conclusions. EVAR has lower rates of 30-day mortality, 30-day MI, and LOS in both elective and ruptured AAA repair.

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

PURPOSE

The purpose of this study is national-level comparison of the endovascular (EVAR) and open repair (OAR) of ruptured abdominal aortic aneurysm (AAA) in the United States from 2001 to 2010.

METHODS

The data were obtained from nationwide inpatient sample from the Department of Health and Human Services. Ruptured AAA treated by OAR or EVAR were selected using combination ICD-9 codes.

RESULTS

There were 42,126 cases of ruptured AAA of which 8,140 (19.3%) were repaired by EVAR. EVAR patients were older (74.1 vs. 72.8 years, p < 0.001) and had higher incidence of comorbidities compared with OAR group. EVAR patients had lower in-hospital mortality (25.9 vs. 39.1%, p < 0.001) and shorter hospital stay (10.4 vs. 13.7 days, p < 0.001). More patients were discharged home following EVAR (36.8 vs. 21.5%, p < 0.001). There was reduced need for institutional rehabilitation following EVAR (26.3 vs. 29.1%, p < 0.001). Females had significantly higher mortality compared with males after both EVAR (32.2 vs. 24.1%, p < 0.001) and OAR (46.2 vs. 36.9%, p < 0.001). The hospital mortality (41.3-25.8%, p < 0.001) and mean length of stay (11.8-9.7 days, p < 0.01) of EVAR steadily improved over the study period.

CONCLUSIONS

National level comparison of data from the past decade shows that in suitable cases, EVAR for ruptured AAA is associated with reduced hospital mortality, shorter hospital stay, and reduced need for rehabilitation. EVAR outcomes showed consistent improvement with time. Regardless of the type of repair, women had higher mortality compared with men.

Nationwide trends in abdominal aortic aneurysm repair and use of endovascular repair in the emergency setting

PURPOSE

To analyze nationwide trends in abdominal aortic aneurysm (AAA) repair and the use of endovascular abdominal aortic aneurysm repair (EVAR) in the emergency setting.

MATERIALS AND METHODS

Data were obtained from the Nationwide Inpatient Sample (NIS) using the International Classification of Diseases, Ninth Revision-Clinical Modification (ICD-9-CM) codes for open and endovascular repairs from 2001-2009. Trends in outcome parameters and hospital charges were compared.

RESULTS

The number of emergency EVAR procedures increased from 382 in 2001 to 1,247 in 2009 (P < .001). During the study period, length of hospital stay associated with total number of EVAR procedures decreased from 3.8 days to 3.4 days (P < .05), and the in-hospital mortality decreased from 2.4% to 2% (P = .32). From 2001-2009, mean hospital charges associated with EVAR increased from $50,630 to $91,401 (74% increase), whereas charges associated with open repairs increased from $54,578 to $128,925 (136% increase). The proportion of patients needing rehabilitation or nursing home placement after EVAR increased from 5.8% to 7.7% (P < .01), and need for home health increased from 6.9% to 10.5% (P < .01).

CONCLUSIONS

There was a significant increase in the number of emergency EVAR procedures during the study period; however, the overall in-hospital mortality associated with EVAR remained unchanged, and the length of hospital stay showed a decreasing trend. The total hospital charges for EVAR were lower than the charges for open abdominal aneurysm repair throughout the study period; the difference in charges between the procedures showed a significant increasing trend with time.

Endovascular repair of ruptured abdominal aortic aneurysm does not confer survival benefits over open repair

OBJECTIVE

Endovascular repair of ruptured abdominal aortic aneurysm (rAAA) is being increasingly performed despite lack of good evidence for its superiority. Other reported studies suffer from patient selection and publication bias with limited follow-up. This study is a single-center propensity score comparing early and midterm outcomes between open surgical repair (OSR) and endovascular repair of rAAA (REVAR).

METHODS

A retrospective review from January 2001 to November 2010 identified 312 patients who underwent rAAA repairs. Thirty-one patients with antecedent AAA repair and three with incomplete records were excluded, leaving 37 REVARs and 241 OSRs. Propensity score-based matching for sex, age, preoperative hemodynamic status, surgeon's annual AAA volume, and preoperative cardiopulmonary resuscitation was performed in a 1:3 ratio to compare outcomes. Thirty-seven REVARs were matched with 111 OSRs. Late survival was estimated by Kaplan-Meier methods.

RESULTS

Operative time and blood replacement were higher with OSR. Overall complication rates were similar (54% REVAR vs 66% OSR; P = .23), except for higher incidences of tracheostomies (21% vs 3%; P = .015), myocardial infarction (38% vs 18%; P = .036), and acute tubular necrosis (47% vs 21%; P = .009) with OSR. Operative mortality rates were similar (22% REVAR vs 32% OSR), with an odds ratio of 0.63 for REVAR (95% confidence interval = [0.24, 1.48]; P = .40). No differences in the incidences for secondary interventions for aneurysm- or graft-related complications were noted (22% REVAR vs 22% OSR; P = .99). Kaplan-Meier estimates of 1-, 2-, and 3-year survival rates were also similar (50%, 50%, 42% REVAR vs 54%, 52%, 47% OSR; P = .66).

CONCLUSIONS

REVAR for rAAA does not seem to conclusively confer either acute or late survival advantages. Routine use of REVAR should be deferred until prospective, randomized trial data become available.

Early and mid-term results of a prospective observational study comparing emergency endovascular aneurysm repair with open surgery in both ruptured and unruptured acute abdominal aortic aneurysms

The aim of the paper is to prospectively describe early and mid-term outcomes for emergency endovascular aneurysm repair (eEVAR) versus open surgery in acute abdominal aortic aneurysms (aAAAs), both unruptured (symptomatic) and ruptured. We enrolled all consecutive patients treated for aAAA at our center between April 2002 and April 2008. The main outcome parameters were 30-day, 6- and 12-month mortality (all-cause and aneurysm-related). Two hundred forty patients were enrolled in the study. In the unruptured aAAA group ( n = 111), 47 (42%) underwent eEVAR. The 30-day, 6- and 12-month mortality rates were 6, 13 and 15% in the eEVAR group versus 11% (NS), 13% (NS) and 16% (NS) in the open group, respectively. In the ruptured aAAA group ( n = 129), 25 (19%) underwent eEVAR (mortality rates: 20, 28 and 36%, respectively) compared with 104 (81%) patients who underwent open surgery (mortality rates: 45% ( P = 0.021), 60% ( P = 0.004) and 63% ( P = 0.014), respectively). In conclusion, the present study showed a reduced 30-day, 6- and 12-month mortality of eEVAR compared with open surgery in all patients with aAAA, mainly due to a lower mortality in the ruptured aAAA group. Late aneurysm-related mortality occurred only in the eEVAR group.

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.

A meta-analysis and metaregression analysis of factors influencing mortality after endovascular repair of ruptured abdominal aortic aneurysms

OBJECTIVE

To determine factors that may influence the perioperative mortality after endovascular repair of ruptured abdominal aortic aneurysms (RAAAs) using metaregression analysis.

METHODS

A meta-analysis of all English-language literature with information on mortality rates after endovascular repair of RAAAs was conducted. A metaregression was subsequently performed to determine the impact on mortality of the following 8 factors: patient age; mid-time study point; anaesthesia; endograft configuration; haemodynamic instability; use of aortic balloon; conversion to open repair; and abdominal compartment syndrome.

RESULTS

The pooled perioperative mortality across the 46 studies (1397 patients) was 24.3% (95% CI: 20.7-28.3%). Of the 8 variables, only bifurcated approach was significantly associated with reduced mortality (p = 0.005). A moderate negative correlation was observed between bifurcated approach and haemodynamic instability (-0.35). There was still a strong association between bifurcated approach and mortality after simultaneously adjusting for haemodynamic instability, indicating that the latter was not a major factor in explaining the observed association.

CONCLUSIONS

Endovascular repair of RAAAs is associated with acceptable mortality rates. Patients having a bifurcated endograft were less likely to die. This may be due to some surgeons opting for a bifurcated approach in patients with better haemodynamic condition. Further studies will be needed to clarify this.

Endovascular treatment of ruptured abdominal aortic aneurysms: aorto-uni-iliac or bifurcated endograft?

PURPOSE

This study evaluated the safety and technical and clinical success rates of positioning endovascular endografts (EG) in ruptured abdominal aneurysms.

MATERIALS AND METHODS

Patients with a ruptured abdominal aortic aneurysm confirmed by contrast-enhanced computed tomography angiography (CTA) were eligible for the analysis. Of 67 patients, 42 (62.7%) were treated with EG. Thirteen patients (30.9%) received an aorto-uni-iliac EG (group A) and 29 a bifurcated EG (group B). Patients were divided for comparative analysis according to the configuration of the EG implanted.

RESULTS

The primary technical success rate was 100%; the primary clinical success rate was 95% (40/42). There were two intraoperative deaths (4.7%) related to intractable shock. No patient required conversion to open repair. Overall, 12 patients (28.5%) died within 30 days. The in-hospital death rate was 30.9% (13/42). Hospital mortality rate was statistically higher in group A; the type of EG and intensive care unit admission were the only independent predictors of hospital mortality.

CONCLUSIONS

In our experience, a higher mortality rate was observed for the aorto-uni-iliac configuration; shock at admission was confirmed as the most important factor for postoperative survival.

Ruptured abdominal aortic aneurysm: Endovascular treatment

Aim

The elective endovascular treatment of abdominal aortic aneurysm (AAA) is nowadays a daily routine practice in selected patients. The traditional treatment of ruptured abdominal aortic aneurysm (rAAA) has a peri-operative mortality of 40–50% that has not changed in the last 20 years. Nowadays, the endovascular repair may reduce mortality, hospitalization and sanitary costs.

Methods

The study included 14 patients affected by AAA who came to the Emergency Department because of hemodynamic shock (nine patients) or back pain (five patients). All patients underwent a CT angiography before surgery. Forty-two percent of the patients presented with shock (systolic pressure ≤70 mm Hg) in the operating room, and they underwent an endovascular aortic repair (EVAR) as an emergency procedure. Five bifurcated endoprotesis and nine uniliac protesis making a femoro-femoral bypass to revascularize the excluded limb were made. Patients underwent a follow up with CT angiography one month and then six months after surgery and if no problems were detected, patients underwent a follow-up every year.

Results

Two cases were immediately converted to open surgery because of failed EVAR. Four patients (28%) died after surgery because of multi-organ failure (MOF). The mean hospitalization was 12 days (range 3–21 days). We observed only one case of first-type endoleak at the 1-month follow up and we successfully treated it with a proximal cuff.

Conclusion

In our experience, the intention-to-treat protocol for rAAA offered acceptable results in terms of mortality rates. Multicenter studies are necessary to establish the role of endovascular treatment in patients with rAAA.

Ruptured abdominal aortic aneurysm: endovascular program development and results

Improvements in endovascular technology and techniques have allowed us to treat patients in ways we never thought possible. Today endovascular treatment of ruptured abdominal aortic aneurysms is associated with markedly decreased morbidity and mortality when compared to the open surgical approach, yet there are several fundamental obstacles in our ability to offer these endovascular techniques to most patients with ruptured aneurysms. This article will focus on the technical aspects of endovascular aneurysm repair for rupture, with particular attention to developing a standardized multidisciplinary approach that will help ones ability to deal with not just the technical aspects of these procedures, but also address some of the challenges including: the availability of preoperative CT, the choice of anesthesia, percutaneous vs. femoral cut-down approach, use of aortic occlusion balloons, need for bifurcated vs. aorto-uniiliac stentgrafts, need for adjunctive procedures, diagnosis and treatment of abdominal compartment syndrome, and conversion to open surgical repair.

Open surgery in endovascular aneurysm repair era: simplified classification in two risk groups owing to factors affecting mortality in 137 ruptured abdominal aortic aneurysms (RAAAs)

Our objective is to identify in 137 true RAAAs operated consecutively in open surgery: (1) diagnostic therapeutic aspects capable of influencing results, (2) risk classes with different prognosis, (3) any situations where the prognosis is so negative that surgery is not recommended. The relationship of 16 anamnestic, clinical and technical parameters prospectively collected with 30-day mortality was retrospectively evaluated by uni- and multivariate analyses. Thirty-day mortality was 37%. The univariate analysis identified as mortality predictors Hb ≤ 8 g/dl and circulatory shock at hospitalisation, but following the multivariate analysis only circulatory shock was a certainly significant risk-factor. The cumulative effect on mortality of the two parameters identified at univariate analysis translates into a statistically significant difference in mortality between two groups of patients: A (no or just one risk-factor) and B (two risk-factors). To reinstate euvolemia, rather than adequate haemoglobin values, improves the chances of success. A simple prognostic index into two risk classes is feasible, but abstention from surgery is not justified in any type of patient.

Ruptured abdominal aortic aneurysm after endovascular aortic aneurysm repair

In treating uncomplicated abdominal aortic aenurysm, endovascular aortic aneurysm repair (EVAR) has been employed as a good alternative to open repair with low perioperative morbidity and mortality. However, the aneurysm can enlarge or rupture even after EVAR as a result of device failure, endoleak, or graft migration. We experienced two cases of aneurismal rupture after EVAR, which were successfully treated by surgical extra-anatomic bypass.