Endovascular repair of ruptured infrarenal abdominal aortic aneurysm is associated with lower 30-day mortality and better 5-year survival rates than open surgical repair

Ruptured AAA: bridging the gap between international guidelines and local clinical realities

BACKGROUND

Treatment of asymptomatic Abdominal Aortic Aneurysms (AAA) presents a clinical challenge, requiring a delicate balance between rupture risk, patient comorbidities, and intervention-related complications. International guidelines recommend intervention for specific AAA size thresholds, but these are based on historical trials with limited female representation. We aimed to analyse disease characteristics, AAA size at rupture, and intervention outcomes in patients with ruptured AAA from 2009 to 2023 to investigate the gap between guidelines and local realities.

METHODS

This single-centre retrospective cohort study analysed electronic health records of patients treated for a ruptured AAA, excluding those who were managed palliatively. The study assessed patients' demographics, risk factors, comorbidities, clinical presentation, radiological characteristics, and outcomes.

RESULTS

Of 164 patients (41 females, 123 males, median age 73.5), 93.3% presented with abdominal or back pain. The median AAA size at rupture was 8.0 cm in males and 7.6 cm in females. No significant correlations were found between demographic characteristics, risk factors, AAA size, repair modality, and outcomes. Trends show a decline in AAA prevalence and rupture rates, aligning with global health initiatives. Post-intervention survival rates at 30 days were 70.7% (67.5% in males and 80.0% in females), and at 2 years were 65.85% (61.7% in males and 70.0% in females).

CONCLUSION

Evolving AAA trends and improved post-intervention survival rates warrant a critical reassessment of existing intervention recommendations. Adjusting intervention thresholds to larger sizes may be justified to optimise the risk-benefit ratio.

Evaluating the Effectiveness and Clinical Outcomes of Endovascular Aneurysm Repair-First Approach for Ruptured Abdominal Aortic Aneurysm in Japan

PURPOSE

To verify the validity of an endovascular aneurysm repair (EVAR)-first strategy for treating patients with ruptured abdominal aortic aneurysm (rAAA) in Japan.

MATERIALS AND METHODS

This study was conducted on 2 groups of patients with rAAA who underwent surgical treatment at 3 hospitals in the Kanagawa Prefecture, Japan, between January 2007 and September 2016. The open surgical treatment group comprised patients with rAAA who underwent open surgical treatment before January 2012; their data were retrospectively collected from their medical records. The EVAR-first strategy group comprised patients with rAAA who underwent treatment based on the Shonan rAAA protocol (SRAP; the standard protocol-based EVAR-first strategy) in or after February 2012; their data were collected prospectively. The short- and long-term treatment outcomes of both groups were compared. In addition, a risk score-based sensitivity analysis (one-to-one matching) was conducted on both groups using a caliper with 0.2 standard deviations of the score.

RESULTS

Of the 163 patients with rAAA, the open surgical and EVAR-first strategy groups comprised 53 and 110 patients, respectively (EVAR: 91.8%, open repair: 8.2%). The 30-day postoperative mortality rate differed significantly, being 42% for the open surgery group and 25% for the EVAR-first strategy group (odds ratio: 0.44, 95% confidence interval: 0.20-0.97). The postoperative survival rates at 6 months, 1 year, and 3 years were 66%, 48%, and 58% for the EVAR-first group, respectively, and 51%, 66%, and 48% for the open surgery group, respectively (p=0.072). In a matched cohort analysis (n=50), the 30-day postoperative mortality rate was 22% for the EVAR-first group and 44% for the open surgery group (odds ratio: 0.35, 95% confidence interval: 0.14-0.90). The postoperative survival rates at 6 months, 1 year, and 3 years were 76%, 76%, and 63% for the EVAR-first group, respectively, and 48%, 45%, and 45% for the open surgery group, respectively (p=0.003).

CONCLUSION

The SRAP-based EVAR-first strategy for rAAA yielded significantly better treatment outcomes than the open surgical strategy. These findings suggest that EVAR should be considered the primary treatment option for rAAA, given its potential to reduce early mortality rates.

CLINICAL IMPACT

Multicenter retrospective analysis of prospectively collected registry data was done to compare treatment outcomes of two groups of ruptured abdominal aortic aneurysm patients open surgery and endovascular-aneurysm-repair (EVAR)-first strategy (Shonan ruptured abdominal aortic aneurysm protocol). EVAR-first group showed better outcomes: lower 30-day mortality (25% vs. 42%), higher survival rates at 6 months, 1 year, and 3 years. Take home Message: The study supports the use of the EVAR-first strategy with the Shonan Protocol for treating ruptured abdominal aortic aneurysms in Japan, showing improved outcomes, reduced 30-day postoperative mortality, and better long-term survival rates compared to the conventional approach.

Modern management of ruptured abdominal aortic aneurysm

Ruptured abdominal aortic aneurysms (rAAA) remain one of the most clinically challenging and technically complex emergencies in contemporary vascular surgery practice. Over the past 30 years, a variety of changes surrounding the treatment of rAAA have evolved including improvements in diagnosis, development of coordinated referral networks to transfer patients more efficiently to higher volume centers, deliberate de-escalation of pre-hospital resuscitation, modification of patient and procedure selection, implementation of clinical pathways, as well as enhanced awareness of certain high-impact postoperative complications. Despite these advances, current postoperative outcomes remain sobering since morbidity and mortality rates ranging from 25%-50% persist among modern published series. Some of the most impactful variation in rAAA management has been fostered by the rapid proliferation of endovascular repair (EVAR) along with service alignment at selected centers to improve timely revascularization. Indeed, clinical care pathways and emergency response networks are now increasingly utilized which has led to improved outcomes contemporaneously. Moreover, evolution in pre- and post-operative physiologic resuscitation has also contributed to observed improvements in rAAA outcomes. Due to different developments in care provision over time, the purpose of this review is to describe the modern management of rAAA, while providing historical perspectives on patient, procedure and systems-based practice elements that have evolved care delivery paradigms in this complex group of patients.

28-Year Experience with Ruptured and Symptomatic Type I-III Thoracoabdominal Aortic Aneurysms at a Large Tertiary Referral Center

BACKGROUND

Given the relative rarity of ruptured and symptomatic type I-III thoracoabdominal aortic aneurysms (TAAA), data is scarce with regard the outcomes of those who survive to repair. The goal of this study was to determine short and long-term outcomes after open repair of type I-III TAAA surgery for ruptured and symptomatic TAAA and compare the results to elective TAAA repairs.

METHODS

All open type I-III TAAA repairs performed from 1987 to 2015 were evaluated using an institutional database. Charts were retrospectively evaluated for perioperative outcomes: major adverse event (MAE), in-hospital death, spinal cord ischemia (SCI) and long-term survival. Ruptured, symptomatic and elective repair cohorts were created for comparison. Univariate analysis was performed using the Fisher's exact test for categorical variables and analysis of variance (ANOVA) for continuous variables. Logistic regression was used for in-hospital endpoints; survival analysis was performed with Cox proportional hazards modelling and Kaplan-Meier techniques.

RESULTS

Five hundred-sixteen patients had an open type I-III TAAA repair during the study period. Fifty-nine (11.4%) were performed for rupture and 51 (9.9%) were performed for symptomatic aneurysms (RAs). Ruptured and symptomatic groups were more likely to be older, female, and have larger presenting aortic diameters. Most of the ruptured and symptomatic cases were transferred from an outside facility (59.3% and 54.9%, respectively). Intraoperatively, the elective cohort was more likely to receive left heart bypass as an operative adjunct; ruptures were less likely to receive a renal bypass, and operative time was highest for the elective cohort. Perioperative mortality was 18.6% for ruptured, 2.0% for symptomatic, and 7.4% for elective indications. Ruptures were most likely to require new hemodialysis after repair (20.3% vs. 10.3% for elective, P = 0.02). On adjusted analysis, ruptures were more likely to suffer from perioperative death (adjusted odds ratio [AOR]: 4.5, 95% confidence interval (CI): 1.7-11.4) and MAEs (AOR: 2.8, 95% CI: 1.4-5.4). Ruptured and symptomatic aneurysms were not independently associated with SCI; however, preoperative hemodynamic instability was predictive (AOR: 8.7, 95% CI: 1.7-44.2). Both rupture and symptomatic cases were associated with decreased survival on Kaplan-Meier analysis with 5-year survival for ruptures at 35%, symptomatic at 47.7% and elective at 63.7%, P < 0.001. Adjusted hazards of death were 1.2 (95% CI: 0.9-1.8) in the symptomatic cohort and 2.3 (95% CI: 1.5-3.7) in the ruptured cohort.

CONCLUSIONS

Open ruptured and symptomatic type I-III TAAA repairs can be performed with acceptable morbidity and mortality. Most symptomatic and rupture repairs were performed after transfer from another institution. Postoperative SCI is most strongly related to the preoperative hemodynamic status of the patient.

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.

The blood sugar level can predict preoperative shock in patients with a ruptured abdominal aortic aneurysm even when the patient's condition appears stable

PURPOSE

This observational retrospective study aimed to identify preoperative blood test data capable of predicting preoperative shock in ruptured abdominal aortic aneurysm (rAAA).

METHODS

A total of 104 patients who underwent surgery for rAAA between 2007 and 2018 were reviewed. Preoperative shock, defined as a shock index (heart rate/blood pressure) exceeding 1.5 or a maximum blood pressure < 80 mmHg, was observed in 44 patients (42%).

RESULTS

Blood sugar (BS) (odds ratio [OR] 1.02; p < 0.001), C-reactive protein (CRP) (OR 0.57; p = 0.005), and hemoglobin (OR 0.60; p = 0.001) levels were identified as independent positive predictors of preoperative shock, and a BS level ≥ 300 mg/dl (OR 13.2; 95% CI 3.56-48.6; p < 0.001) was identified as a positive predictor of preoperative shock. The receiver operating characteristics curve analysis for BS showed that the area under the curve for the predicted probabilities was 0.84, and at a cut-off value of 215 mg/dl, the sensitivity of minimum BS for predicting preoperative shock was 86% with a specificity of 79%.

CONCLUSIONS

The BS level is as an independent predictor of preoperative shock in patients with rAAA. Patients with preoperative BS levels ≥ 300 mg/dl have an extremely high risk of preoperative shock.

Controversies in Vascular Surgery

There have been significant advances in vascular surgery in recent years. These advances include procedural techniques, choice of procedure, and application of nonoperative management. Endovascular techniques have expanded greatly over the past decade. As a result, for many clinical scenarios there is more than 1 option for management, which has given rise to controversies in the choice of best management. This article reviews current controversies in the management of carotid artery disease, abdominal aortic aneurysms, acute deep venous thrombosis, and inferior vena cava filter placement.

Time-to-event data meta-analysis of late outcomes of endovascular versus open repair for ruptured abdominal aortic aneurysms

OBJECTIVE

We investigated whether the well-documented perioperative survival advantage of emergency endovascular aneurysm repair (EVAR) compared with open repair would be sustained during follow-up.

METHODS

A systematic review conforming to the PRISMA (preferred reporting items for systematic reviews and meta-analyses) statement standards was conducted to identify studies that had reported the follow-up outcomes of endovascular vs open repair for ruptured abdominal aortic aneurysms. Electronic bibliographic sources (MEDLINE [medical literature analysis and retrieval system online], Embase [Excerpta Medica database], CINAHL [cumulative index to nursing and allied health literature], and CENTRAL [Cochrane central register of controlled trials]) were interrogated using the Healthcare Databases Advanced Search interface (National Institute for Health and Care Excellence, London, United Kingdom). A time-to-event data meta-analysis was performed using the inverse variance method, and the results were reported as summary hazard ratios (HRs) and associated 95% confidence intervals (CIs). Mixed effects regression was applied to investigate the outcome changes over time. The quality of the body of evidence was appraised using the GRADE (grades of recommendation, assessment, development, and evaluation) system.

RESULTS

Three randomized controlled trials and 22 observational studies reporting a total of 31,383 patients were included in the quantitative synthesis. The mean follow-up duration across the studies ranged from 232 days to 4.9 years. The overall all-cause mortality was significantly lower after EVAR than after open repair (HR, 0.79; 95% CI, 0.73-0.86). However, the postdischarge all-cause mortality was not significantly different (HR, 1.10; 95% CI, 0.85-1.43). The aneurysm-related mortality, which was reported by one randomized controlled trial, was not significantly different between EVAR and open repair (HR, 0.89; 95% CI, 0.69-1.15). Meta-regression showed the mortality difference in favor of EVAR was more pronounced in more recent studies (P = .069) and recently treated patients (P = .062). The certainty for the body of evidence for overall and postdischarge all-cause mortality was judged to be low and that for aneurysm-related mortality to be high.

CONCLUSIONS

EVAR showed a sustained mortality benefit during follow-up compared with open repair. A wider adoption of an endovascular-first strategy is justified.

Endovascular Treatment of Ruptured Abdominal Aortic Aneurysms

Since its inception in the 1990s, endovascular aortic repair has quickly replaced traditional open aortic repair (OAR) as the most common method for elective treatment of abdominal aortic aneurysms (AAA). After numerous iterations and failures of different endografts, the technology has undergone dramatic improvements with evidence pointing to this technology serving as a safe and durable modality, albeit with the requirement of routine surveillance. Not surprisingly, the ability to treat patients with AAAs with minimally invasive technology that could theoretically mitigate some of the risks associated with OAR, such as aortic cross clamping and significant blood loss, was also adopted in patients with ruptured AAAs and is now the preferred treatment method if anatomically feasible.

Endograft type and anesthesia mode are associated with mortality of endovascular aneurysm repair for ruptured abdominal aortic aneurysms

OBJECTIVE

Endovascular aneurysm repair has become the primary treatment modality for ruptured infrarenal abdominal aortic aneurysm. This study examines the impact of endograft type on perioperative outcomes for ruptured infrarenal abdominal aortic aneurysm.

METHOD

The targeted endovascular aneurysm repair files of the American College of Surgeons National Surgical Quality Improvement Program database (2012-2017) were used. Only patients treated for ruptured infrarenal abdominal aortic aneurysm were included. All patients requiring concomitant stenting of the visceral arteries or aneurysmal iliac arteries or open abdominal surgery were excluded. The characteristics of patients treated with the different endografts and the corresponding outcomes were compared using Stata software.

RESULTS

There were 479 patients treated with the three most common endografts: Cook Zenith (n = 127), Gore Excluder (n = 239), and Medtronic Endurant (n = 113). The number of other endografts was too small for statistical analysis. Compared to patients treated with Excluder or Endurant, the patients treated with Zenith had significantly lower body mass index (P < .001) and were less likely to be white (P < .001). On the other hand, patients treated with Endurant were less likely to be smoker (P = .016). Patients treated with Zenith had significantly larger ruptured infrarenal abdominal aortic aneurysm diameter (P = .045). The overall mortality was 18% and morbidity 74.3%. There was a statistically significant difference in overall mortality (Zenith = 11.8%, Excluder = 18%, Endurant = 24.8%, P = .033) but not morbidity (P = .808) between the three groups. Post hoc analysis for overall mortality showed only significant difference between Zenith and Endurant. The difference in mortality was not significant in patients presenting with ruptured infrarenal abdominal aortic aneurysm without hypotension (P = .065). On multivariable analysis, treatment with the Endurant endograft was associated with increased mortality compared to Zenith (odds ratio = 3.0 [confidence interval 1.31-6.7]). General anesthesia (odds ratio = 2.67 [confidence interval 1.02-7.02]), rupture with hypotension (odds ratio = 4.49 [confidence interval 2.54-7.95]), and dependent functional status (odds ratio = 5.7 [confidence interval 1.96-16.59]) were independently associated with increased mortality while increasing body mass index (odds ratio = 0.97 [confidence interval 0.95-0.99]) was associated with reduced risk of mortality.

CONCLUSIONS

This study highlights contemporary outcomes of endovascular aneurysm repair for ruptured infrarenal abdominal aortic aneurysm with relatively low mortality. Endograft type and anesthesia technique are modifiable factors that can potentially improve outcomes. Significant variation in the outcomes of the different endografts warrants further research.

Long-term Outcomes Following Endovascular Aneurysm Repair for Ruptured Abdominal Aortic Aneurysms

Purpose: To investigate the long-term outcomes of endovascular aneurysm repair (EVAR) for ruptured abdominal aortic aneurysm (rAAA) from a single center over an 11-year period. Materials and Methods: A retrospective analysis was conducted of 121 patients (median age 78 years; 100 men) with rAAA who underwent emergency EVAR at a single tertiary vascular center from January 2006 to December 2016. The study included only ruptures confirmed by evidence of hematoma on preoperative computed tomography; both iliac and aortic aneurysm ruptures were eligible. The primary outcome measures included mortality and reintervention rates. Kaplan-Meier estimates of survival and freedom from reintervention are reported with the 95% confidence interval (CI). Results: In-hospital and 30-day mortality rates for emergency EVAR were 16.5%; 90-day mortality was 24.0%. The mortality estimates were 27.3% (95% CI 20% to 36%) at 1 year and 61.7% (95% CI 51% to 72%) at 5 years. In the observation period to 2017, 63 reinterventions were performed on 37 patients (30.6%). Median time to the first reintervention was 3.2 years. Freedom from reintervention in surviving patients at 1 year was 86% (95% CI 72% to 94%) and 51% (95% CI 26% to 71%) at 5 years. Four patients (3.3%) had a secondary sac rupture over the study period. Conclusion: Emergency EVAR for ruptured AAA can be performed with acceptable short-term outcomes; however, long-term surveillance is necessary, and reintervention is common.

Patients with a Ruptured Abdominal Aortic Aneurysm Are Better Informed in Hospitals with an "EVAR-preferred" Strategy: An Instrumental Variable Analysis of the Dutch Surgical Aneurysm Audit

BACKGROUND

While several observational studies suggested a lower postoperative mortality after minimal invasive endovascular aneurysm repair (EVAR) in patients with a ruptured abdominal aortic aneurysm (RAAA) compared to conventional open surgical repair (OSR), landmark randomized controlled trials have not been able to prove the superiority of EVAR over OSR. Randomized controlled trials contain a selected, homogeneous population, influencing external validity. Observational studies are biased and adjustment of confounders can be incomplete. Instrumental variable (IV) analysis (pseudorandomization) may help to answer the question if patients with an RAAA have lower postoperative mortality when undergoing EVAR compared to OSR.

METHODS

This is an observational study including all patients with an RAAA, registered in the Dutch Surgical Aneurysm Audit between 2013 and 2017. The risk difference (RD) in postoperative mortality (30 days/in-hospital) between patients undergoing EVAR and OSR was estimated, in which adjustment for confounding was performed in 3 ways: linear model adjusted for observed confounders, propensity score model (multivariable logistic regression analysis), and IV analysis (two-stage least square regression), adjusting for observed and unobserved confounders, with the variation in percentage of EVAR per hospital as the IV instrument.

RESULTS

2419 patients with an RAAA (1489 OSR and 930 EVAR) were included. Unadjusted postoperative mortality was 34.9% after OSR and 22.6% after EVAR (RD 12.3%, 95% CI 8.5-16%). The RD adjusted for observed confounders using linear regression analysis and propensity score analysis was, respectively, 12.3% (95% CI 9.6-16.7%) and 13.2% (95%CI 9.3-17.1%) in favor of EVAR. Using IV analysis, adjusting for observed and unobserved confounders, RD was 8.9% (95% CI -1.1-18.9%) in favor of EVAR.

CONCLUSIONS

Adjusting for observed confounders, patients with an RAAA undergoing EVAR had a significant better survival than OSR in a consecutive large cohort. Adjustment for unobserved confounders resulted in a clinical relevant RD. An "EVAR preference strategy" in patients with an RAAA could result in lower postoperative mortality.

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.

Treatment Strategy of Endovascular versus Open Repair for Ruptured Abdominal Aortic Aneurysm Based on the Fitzgerald Classification

BACKGROUND

The Fitzgerald classification expresses the extension of hematoma from the ruptured abdominal aortic aneurysm (rAAA) and is related to a patient's preoperative status. The objective of this study was to propose a new decision-making method for emergency surgeries, endovascular aortic repair (EVAR), or open repair (OR) for rAAA based on the Fitzgerald classification using preoperative computed tomography images.

MATERIALS AND METHODS

A multicenter observational study was performed with a questionnaire survey of rAAA from August 2010 to July 2015 in Hokkaido, Japan, and sent to 20 institutions participating in the Hokkaido Society of Aortic Stent Graft. We included 205 patients who could be stratified by the Fitzgerald classification as the subjects of this study. We categorized these patients into Fitzgerald classes I and II (first category, n = 72) and classes III and IV (second category, n = 133). The short-term results of both EVAR and OR cases were examined in the 2 categories.

RESULTS

In the first category, patients in the EVAR group were older than those in the OR group. Nonetheless, the in-hospital mortality rate was lower in the EVAR group than in the OR group (0% vs. 18%; P = 0.019). In the second category, there was no difference in preoperative factors between the groups. The EVAR group showed a higher incidence rate of postoperative abdominal compartment syndrome than the OR group (12% vs. 2%; P = 0.042). The in-hospital mortality rate was comparable between the groups (24% vs. 25%; P = 0.80). Although there were no deaths in the EVAR group without preoperative shock, in-hospital mortality in the EVAR group of the second category with shock was 41% (vs. 28% in the OR group; P = 0.27). Furthermore, mortality in the EVAR group with Fitzgerald class IV was 100% (vs. 29% in the OR group; P = 0.049).

CONCLUSIONS

EVAR is recommended in Fitzgerald class I or II and also in Fitzgerald class III or IV without shock because the results of EVAR were better than those of OR. Because all patients who underwent EVAR died in Fitzgerald class IV, OR would be beneficial in this patient population.

Isolated mycotic hypogastric artery aneurysm

Isolated iliac artery aneurysms are rare and commonly associated with aortic aneurysms. Hypogastric artery aneurysms (HAAs) are exceptionally rare. The general approach to HAAs has been exclusion and bypass, although when this is complicated by mycotic disease, endovascular techniques can provide unique approaches to management. We present the case of a patient with a mycotic HAA treated with endovascular coil and exclusion followed by aortic to external iliac artery bypass with cadaveric conduit.

Endovascular management of ruptured abdominal aortic aneurysms and acute aortic dissections

The management of vascular emergencies is dependent on rapid identification and confirmation of the diagnosis with concurrent patient stabilization prior to immediate transfer to the operating suite. A variety of technological advances in diagnostic imaging as well as the advent of minimally invasive endovascular interventions have shifted the contemporary treatment algorithms of such pathologies. This review provides a comprehensive discussion on the current state and future trends in the management of ruptured abdominal aortic aneurysms as well as acute aortic dissections.

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.

Endovascular Aneurysm Repair-First Strategy for Ruptured Aneurysm Focuses on Fitzgerald Classification and Vein Thrombosis

BACKGROUND

Recent study have demonstrated the good results of endovascular aneurysm repair (EVAR) for ruptured abdominal aortic aneurysms (RAAAs). We report on the results of our EVAR-first strategy for RAAAs focuses on Fitzgerald (F) classification and vein thrombosis.

MATERIALS AND METHODS

From 2011 to 2017, 31 patients with RAAA underwent EVAR at our hospital. We compared F-1 patients (group A) with F-2 to F-4 patients with obvious retroperitoneal hematoma (group B).

RESULTS

The baseline characteristics in group A (n = 9) and group B (n = 22) were similar. In group B, there were 8 cases of F-2, 10 cases of F-3, and 4 cases of F-4. Of the 22 cases in group B, 16 (73%) cases involved preoperative shock. Operation time was not significantly different (group A: 147 min and group B: 131 min, P = 0.48). The total mortality rate of group A and group B combined was 77.4%. The 30-day mortality was 0% for group A and 23.8% for group B, in which there were 2 F-4 cases and 3 F-3 cases. In group B, hematoma-related complications developed in 6 cases (deep vein thrombosis: 4 cases, abdominal compartment syndrome: 1 case, and hematoma infection: 1 case), and 1 case with deep vein thrombosis developed a pulmonary embolism that resulted in cardiac arrest. The 3-year survival rate was significantly higher for group A (100% vs. 52.3%, P = 0.016), but the freedom from aortic death rate was not significantly different (100% vs. 66.7%, P = 0.056).

CONCLUSIONS

Using EVAR for RAAA is a valid strategy. Certain complications that are associated with peritoneal hematoma, especially venous thrombosis, should receive particular attention.

The Adoption of Surgical Innovations at Academic Versus Nonacademic Health Centers

PURPOSE

The value of the health care services provided by academic health centers (AHCs) in the United States increasingly is being questioned. AHCs play a prominent role in developing new surgical innovations, including new minimally invasive techniques, which are costly up front but can lead to significant benefits like decreased morbidity and lengths of stays. This study explored the role of AHCs in the adoption of these surgical innovations as a novel measure of their value.

METHOD

The authors combined data from the American Hospital Association and the State Inpatient Databases from California, Florida, Washington State, and New York. They compared the number and percentage of patients who received four new, innovative surgical procedures (vs. those who received the traditional procedures) at Council of Teaching Hospitals (COTH) hospitals to those at non-COTH hospitals from 2009 to 2011.

RESULTS

Overall, 61.1% (27,175) of the procedures performed at COTH hospitals used new techniques, compared with 47.2% (41,680) at non-COTH hospitals, across all years (P < .0001). The number and percentage of procedures using the new techniques increased in all years and for all procedures.

CONCLUSIONS

Not only do AHCs play a role in developing surgical innovations but they also adopt these new techniques more quickly than other hospitals, and thereby they provide additional benefits to patients. These findings provide an important and understudied perspective on the value of AHCs.

Contemporary outcomes for ruptured abdominal aortic aneurysms using endovascular balloon control for hypotension

OBJECTIVE

Ruptured abdominal aortic aneurysm (rAAA) continues to portend significant mortality, despite ruptured endovascular aneurysm repair (rEVAR), enhanced perioperative care, and endovascular balloon control (EBC) for hypotension. We review our academic institution's experience using a protocol of EBC for all hypotensive patients, irrespective of type of repair.

METHODS

A retrospective review was conducted of 66 cases of rAAA treated at a single academic institution from 2007 to 2016 using EBC for hypotensive patients. Demographics, comorbidities, intraoperative parameters, and clinical outcomes were recorded. Patients were studied with respect to hemodynamic status, rEVAR, or ruptured open aortic repair in the setting of EBC for hypotension.

RESULTS

rEVAR was performed in 43 patients (65%) and ruptured open aortic repair in 23 patients (35%). rAAA was treated in 51 men (77%). Mean rAAA size was 7.6 mm, and mean age of the patients was 73 years. Perioperative survival was 82%. Overall survival at 30 days, 1 year, and 5 years was 71%, 65%, and 52%. Blood transfusion and severe hypotension were significant predictors of mortality at 30 days on multivariable analysis (odds ratio of 1.2 [P = .08] and 39 [P = .03], respectively). Severe hypotension was defined as a mean arterial blood pressure <65 mm Hg and vasopressor use and was present in 59% of the cohort. Normotension was defined as an absence of these conditions and was present in 12%, with 29% of patients exhibiting moderate hypotension. There was no difference in 30-day survival between normotensive and moderately hypotensive patients. The 30-day survival for severely hypotensive patients was 61% vs 85% for moderately hypotensive patients (P = .003), with a significant difference between groups that persisted at 1 year (85% vs 51%; P = .008) and 5 years (66% vs 51%; P = .017).

CONCLUSIONS

Good midterm outcomes for moderately hypotensive and normotensive patients can be obtained using an EBC protocol for hypotension with a regionalized transport system directly to the operating room. Severely hemodynamically unstable rAAA patients still pose a significant challenge despite mitigation of hypotension by EBC, suggesting that survival may be compromised by factors other than hypotension alone. We still advocate for the use of EBC for all hypotensive patients as part of a defined rAAA protocol before definitive repair.

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.

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.

Outcomes After Use of Aortouniiliac Endoprosthesis Versus Modular or Unibody Bifurcated Endoprostheses for Endovascular Repair of Ruptured Abdominal Aortic Aneurysms

OBJECTIVES

Outcomes after endovascular repair (EVAR) of ruptured abdominal aortic aneurysms (rAAAs) have been widely published. There is, however, controversy on the role of the use of aortouniiliac endoprosthesis (AUI) versus modular or unibody bifurcated endoprosthesis (MUB) for repair of rAAAs. We study and compare 30-day outcomes after use of AUI and MUB for all rAAAs focusing specifically on patients with instability.

MATERIALS AND METHODS

Patients who underwent EVAR for rAAA (n = 425) using AUI (n = 55; 12.9%) and MUB (n = 370; 87.1%) were identified from the American College of Surgeons' National Surgical Quality Improvement Program (2005-2010) database. Univariable and multivariable logistic regression analyses were performed.

RESULTS

No significant difference ( P > .5) was seen in comorbidities between patients who underwent EVAR with AUI or MUB; there was also no change in endoprosthesis use from 2005 to 2010 ( P = .7). Patients who underwent EVAR with AUI more commonly had a history of peripheral arterial procedure (10.9% vs 4.6%; P = .053) and preoperative transfusion of >4 U packed red blood cells (18.2% vs 6.8%; P = .004). Use of AUI versus MUB was associated with more 30-day wound complications (16.4% vs 6.2%; P = .01), return to operating room (38.2% vs 20.0%; P = .003), and mortality (34.5% vs 21.4%; P = .03). On multivariable analysis, use of AUI was associated with an increased risk of 30-day mortality (odds ratio: 2.4; 95% confidence interval: 1.1-5.3). On subanalysis of the cohort for only the patients with unstable rAAA (n = 159; AUI = 29 and MUB = 130), 30-day mortality for AUI versus MUB was still higher but not statistically significant (44.8% vs 32.3%; P = .2).

CONCLUSION

Endovascular repair for ruptured AAA using aortouniliac endoprosthesis is associated with higher 30-day mortality than using modular or unibody bifurcated endoprosthesis.

Pulmonary Embolism due to Inferior Vena Cava Compression by a Retroperitoneal Hematoma after Endovascular Repair of a Ruptured Abdominal Aortic Aneurysm

We report a case of a patient with a residual hematoma compressing the inferior vena cava after endovascular aneurysm repair (EVAR), which led to a pulmonary embolism (PE). A 65-year-old man underwent emergent EVAR for a ruptured aortic aneurysm in the right retroperitoneal region. He developed sudden chest pain at midnight of the fifth day after EVAR, and computed tomography demonstrated a massive PE. He subsequently went into cardiopulmonary arrest. This case suggested that abdominal complications due to a residual hematoma, including deep vein thrombosis and PE, should be considered in addition to compartment syndrome.

Predictors of renal dysfunction after endovascular and open repair of abdominal aortic aneurysms

OBJECTIVE

Renal complications after repair of abdominal aortic aneurysms (AAAs) have been associated with increased morbidity and mortality. However, limited data have assessed risk factors for renal complications in the endovascular era. This study aimed to identify predictors of renal complications after endovascular AAA repair (EVAR) and open repair.

METHODS

Patients who underwent EVAR or open repair of a nonruptured infrarenal AAA between 2011 and 2013 were identified in the National Surgical Quality Improvement Project Targeted Vascular module. Patients on hemodialysis preoperatively were excluded. Renal complications were defined as new postoperative dialysis or creatinine increase >2 mg/dL. Patient demographics, comorbidities, glomerular filtration rate (GFR), operative details, and outcomes were compared using univariate analysis between those with and without renal complications. Multivariable logistic regression was used to identify independent predictors of renal complications.

RESULTS

We identified 4503 patients who underwent elective repair of an infrarenal AAA (EVAR: 3869, open repair: 634). Renal complication occurred in 1% of patients after EVAR and in 5% of patients after open repair. There were no differences in comorbidities between patients with and without renal complications. A preoperative GFR <60 mL/min/1.73m2 occurred more frequently among patients with renal complications (EVAR: 81% vs 37%, P < .01; open: 60% vs 34%, P < .01). The 30-day mortality was also significantly increased (EVAR: 55% vs 1%, P < .01; open: 30% vs 4%, P < .01). After adjustment, renal complications were strongly associated with 30-day mortality (odds ratio [OR], 38.3; 95% confidence interval [CI], 20.4-71.9). Independent predictors of renal complications included GFR <60 mL/min/1.73m2 (OR, 4.6; 95% CI, 2.4-8.7), open repair (OR, 2.6; 95% CI, 1.3-5.3), transfusion (OR, 6.1; 95% CI, 3.0-12.6), and prolonged operative time (OR, 3.0; 95% CI, 1.6-5.6).

CONCLUSIONS

Predictors of renal complications include elevated baseline GFR, open approach, transfusion, and prolonged operative time. Given the dramatic increase in mortality associated with renal complications, care should be taken to use renal protective strategies, achieve meticulous hemostasis to limit transfusions, and to use an endovascular approach when technically feasible.

Significant regional variation exists in morbidity and mortality after repair of abdominal aortic aneurysm

OBJECTIVE

Limited data exist comparing perioperative morbidity and mortality after open and endovascular abdominal aortic aneurysm (AAA) repair (EVAR) among regions of the United States. This study evaluated the regional variation in mortality and perioperative outcomes after repair of AAAs.

METHODS

The Vascular Quality Initiative (VQI) was used to identify patients undergoing open AAA repair and EVAR between 2009 and 2014. Ruptured and intact aneurysms were evaluated separately, and the analysis of intact aneurysms was limited to infrarenal AAAs. All 16 regions of the VQI were deidentified, and those with <100 open repairs were combined to eliminate the effect of low-volume regions. Regional variation was evaluated using χ² and Fisher exact tests. Regional rates were compared against current quality benchmarks.

RESULTS

Perioperative outcomes from 14 regions were compared. After open repair of intact aneurysms, no significant variation was seen in 30-day or in-hospital mortality; however, multiple regions exceeded the Society for Vascular Surgery benchmark for in-hospital mortality after open repair of intact aneurysms of <5% (range, 0%-7%; P = .55). After EVAR, all regions met the Society for Vascular Surgery benchmark of <3% (range, 0%-1%; P = .75). Significant variation in in-hospital mortality existed after open (14%-63%; P = .03) and endovascular (3%-32%; P = .03) repair of ruptured aneurysms across the VQI regional groups. After repair of intact aneurysms, wide variation was seen in prolonged length of stay (>7 days for open repair: 32%-53%, P = .54; >2 days for EVAR: 16-43%, P < .01), transfusion (open: 10%-35%, P < .01; EVAR: 7%-18%, P < .01), use of vasopressors (open: 19%-37%, P < .01; EVAR: 3%-7%, P < .01), and postoperative myocardial infarction (open: 0%-13%, P < .01; EVAR: 0%-3%, P < .01). After open repair, worsening renal function (6%-18%; P = .04) and respiratory complications (6%-20%; P = .20) were variable across regions. The frequency of endoleak at completion of EVAR also had considerable variation (15%-38%; P < .01).

CONCLUSIONS

Despite limited variation, multiple regions do not meet current benchmarks for in-hospital mortality after open AAA repair for intact aneurysms. Significant regional variation exists in perioperative outcomes and length of stay, and mortality is widely variable after repair for rupture. These data identify important areas for quality improvement initiatives and clinical practice guidelines.

Ruptured abdominal aortic aneurysm: Is endovascular aneurysm repair the answer for everybody?

Treatment paradigms for elective repair of asymptomatic abdominal aortic aneurysms (AAA) have evolved during the past 2 decades, with endovascular aneurysm repair as the preferred treatment modality. The patient care strategy for emergent treatment for ruptured AAA is not as straightforward, due in part to surgeon expertise and stent-graft availability at the institution. Although most reports have extrapolated elective endovascular aneurysm repair feasibility data to the ruptured AAA patient and the aneurysm anatomy, these expectations should be interpreted with caution. In the absence of level I evidence, and lack of adequate local hospital resources, endovascular aneurysm repair-first policy might not be feasible for all the patients who present with ruptured AAA.

Perceived barriers to endovascular repair of ruptured abdominal aortic aneurysm among Australasian vascular surgeons

OBJECTIVE

Although endovascular abdominal aortic aneurysm (AAA) repair (EVAR) is widely accepted for elective surgery, the uptake of emergency EVAR for ruptured AAA (REVAR) has trailed behind. This study was intended to identify the barriers to widespread application of REVAR in Australia and New Zealand.

METHODS

A cross-sectional survey of members of the Australia and New Zealand Society of Vascular Surgeons was performed in late 2013. Primary themes explored were (1) perceived barriers to performing REVAR and (2) advantages of REVAR compared with open repair. Secondary data measures were the volume of AAA surgery, standard protocol use, and staff accreditation among vascular units.

RESULTS

A total of 85 surgeons responded to an anonymous online questionnaire (41% response rate); of these, 23 surgeons (27%) had no experience with REVAR, and 65% currently perform more EVAR than open repair for elective procedures, compared with 18% for ruptured AAA. Of the perceived barriers explored, respondents agreed that poor availability of endovascular facilities (73% agreed or strongly agreed) and ancillary staff (56%) were barriers to REVAR. Most surgeons agreed that the advantages of REVAR include reduced intraoperative blood loss, length of stay, and postoperative complications. Four of 11 vascular units performing REVAR had standard protocols in use, and four had mandatory staff accreditation.

CONCLUSIONS

The most common barrier to REVAR identified by surgeons was the poor availability of endovascular facilities, many of which are not ideally suited for this type of procedure. Australian and New Zealand vascular units have low rates of standard protocol use and staff accreditation for REVAR, which may have implications for patient care.