A population-based study of post-endovascular aortic repair rupture during 15 years

Abstract

Objective: The devastating event of a ruptured abdominal aortic aneurysm (rAAA) in patients who have survived a previous AAA repair, either elective or urgent, is a feared and quite uncommon event. It has been suggested to partly explain the loss of the early survival benefit for endovascular aortic repair (EVAR) vs open surgical repair (OSR). The main objective of this study was to report the national incidence rate, risk factors and outcome of post-EVAR ruptures. Secondarily, the national incidence rate of ruptures after OSR (post-OSR ruptures) was investigated.Methods: We conducted a nationwide, population-based, retrospective cohort study using the inpatient and outpatient entries for all patients >40 years of age, receiving their first (index) surgical procedure for AAA, from 2001 to 2015. Only patients surviving their index procedure were included. The primary outcome was rAAA, registered after discharge from the index procedure (EVAR or OSR), identified in the Swedish National Patient Registry and the Cause of Death Registry.Results: In total, 14,859 patients survived their primary (index) AAA procedure. There were 6470 EVAR procedures, 5893 for intact AAA (iAAA) and 577 for rAAA. Of the 6470 EVAR patients, 86 cases of post-EVAR rupture were identified, corresponding with a cumulative incidence of 1.3% over a mean follow-up time of 3.9 years. The incidence rate was 3.4 (95% confidence interval [CI], 2.7-4.2)/1000 person-years. The independent risk factors identified for post-EVAR rupture were rAAA at index surgery HR 2.4 (95% CI, 1.4-4.1, p 0.002) and age (hazard ratio, 1.1; 95% CI, 1.0-1.1; P < .001). Freedom from post-EVAR rupture was 99%, 98%, and 96% at 3, 5, and 10 years, respectively. Total and postoperative mortality after post-EVAR rupture were 42% and 17% (30 days), 45% and 22% (90 days), and 53% and 33% (1 year). The incidence rate of post-OSR rupture was 0.9/1000 person-years (95% CI, 0.7-1.2).Conclusions: Post-EVAR rupture is a rare complication that can occur at any time after the index EVAR procedure. This finding may have implications for the discussion of limited follow-up programs and for the choice of procedure in patients with an AAA with a long life expectancy. An rAAA as the indication for the index surgery and age were identified as risk factors for post-EVAR rupture. The mortality associated with post-EVAR rupture is high, but lower than that of primary rAAA. The much lower risk of post-OSR rupture was confirmed, but must not be neglected as a possible late complication.

Re-Rupture 2 Years after Endovascular Aortic Aneurysm Repair Rupture

“…9 Additionally, a recent study describing 86 patients with post-EVAR ruptures showed that a rAAA as the index surgery almost doubled the risk for post-EVAR rupture (hazard ratio 2.4). 2 In this study, 16 cases (out of all 86 post-EVAR ruptures; 18.6%) with rAAA as the cause were described; the mean time to post-EVAR rupture was 16 months compared to 47 months in patients with intact AAAs at index. Interestingly, 5 out of the 15 admitted patients were not treated and subsequently no safe conclusions regarding the outcome of this subgroup of patients can be extracted.…”

“…Aortic occlusion balloon is indicated in hemodynamically unstable patients. [2][3][4][5] Stent-graft extensions to proximal anchoring sites (cuffing, palmarization stents, embolization techniques) or distally (bridging stent-graft) can occlude the aneurysm. If the aneurysm is not anatomically feasible for secondary EVAR or the patient is hemodynamically unstable, open conversion may be performed.…”

“…1 According to a recent study, incidences of rupture after EVAR is 1.3% for a mean follow-up of 3.9 years, whereas freedom is 99%, 98%, and 96% at 3, 5, and 10 years, respectively, emphasizing the need for short, medium and long-term follow-ups. 2 The mortality rate associated with post-EVAR rupture is high, ranging from 30% to 60%, [1][2][3] and has been considered and deemed lower than that of primary "de-novo" ruptured abdominal aortic aneurysms (rAAAs). However, there are no convincing comparative studies.…”

Japanese single-center experience of abdominal aortic aneurysm repair over 20 years: should open or endovascular aneurysm repair be performed first?

“…Two of these four cases of rupture resulted in death, while the other two were successfully treated by emergent re-intervention (re-EVAR in one and OAR in one). The incidence rate of late rupture is reported to be 1.3–7% [ 7 , 22 – 25 ]. A Swedish national investigation performed by Andersson et al demonstrated that the independent risk factors for late rupture were ruptured AAA at initial EVAR and age.…”

“…The rate of late aneurysm rupture in the present study was comparable to that in previous studies. This complication must not be neglected, and close long-term follow-up after EVAR is required [ 7 , 21 – 25 ].…”