Comparison of Open and Endovascular Repair of Ruptured Abdominal Aortic Aneurysms From the ACS-NSQIP 2005–07

Abstract

Purpose: To compare endovascular (EVAR) and open surgical repair (OSR) for ruptured abdominal aortic aneurysms (RAAA) in terms of preoperative hemodynamic status and comorbidities. Methods: The 2005 to 2007 American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was interrogated to find all patients undergoing repair for RAAA. Of the 567 RAAA repairs identified, 121 (21%) were endovascular and 446 (79%) were open. Demographics, comorbidities, and preoperative hemodynamic status were compared by repair method. Results: Age, sex, and race were similar between repair cohorts. EVAR patients had greater incidences of recent myocardial infarction (7% versus 2%, p<0.05), revascularization or amputation for peripheral vascular disease (8% versus 3%, p<0.05), and cerebrovascular disease (22% versus 11%, p<0.01). Preoperative hemodynamic status was similar based on need for >4 units of blood (3% versus 6%, p=0.31), intubation (12% versus 17%, p=0.18), impaired sensorium (7% versus 11%, p=0.25), coma (4% versus 5%, p=0.65), acute renal failure (2% versus 2%, p=0.60), and ASA class 5 (29% versus 34%, p=0.29). Open repair was associated with greater operative time (3.3 versus 2.6 hours, p<0.01) and intraoperative blood transfusions (8 versus 2 units, p<0.001). Overall mortality was 33.5% (EVAR 24% versus OSR 36%; OR 1.8, 95% CI 1.1 to 2.8, p<0.05). After adjusting for preoperative comorbidities and all preoperative hemodynamic variables, mortality after open repair was greater than after EVAR (OR 1.9, 95% CI 1.1 to 3.2, p<0.05). Overall postoperative complications were greater after open repair (62% versus 47%, p<0.01). Graft failure requiring reintervention was higher after EVAR (4% versus 1%, p<0.05), while rates of return to the operating room for a major operation were similar (21% versus 24%, p=0.43). Conclusion: For RAAA within NSQIP hospitals in recent years, preoperative hemodynamic status was similar between EVAR and OSR, but EVAR patients had greater comorbidities. Despite this and after accounting for minor differences in hemodynamic status, EVAR mortality was lower than OSR mortality. Institutions with adequate experience and resources should attempt endovascular repair for RAAA when anatomy allows.

Renal Function is the Main Predictor of Acute Kidney Injury after Endovascular Abdominal Aortic Aneurysm Repair

“…As a result, preventing AKI is crucial in improving outcome, especially in populations at high-risk, such as those undergoing EVAR. The predictive factors of AKI after elective EVAR are not well determined, as the randomized studies have not reported AKI-incidence and the majority of case-series have not used a consistent AKI definition (16)(17)(18)(19)(20).…”

Treatment of Ruptured Abdominal Aortic Aneurysms: State of the Art

“…Despite many observational studies point favorable outcomes for EVAR when compared to OR, these were not reproduced in the major RCTs. [13][14][15][17][18][19][20] Intuitively, the low-invasive profile makes EVAR particularly appealing for rAAA patients: treatment under local anesthesia with lower associated hypotension are more suitable for bleeding patients. Additionally, there is a reduced procedural risk for elderly comorbid patients, usually not considered for open repair.…”

“…While no differences on inhospital mortality was found on the first, all the four observational studies included presented lower in-hospital mortality for EVAR. [13][14][15][16][17]19,20 Additionally, lower post-operative complications and shorter stay is also reported for EVAR both in RCT and administrative registries. [15][16][17][18][19] For this reason, it is difficult to draw definite conclusions.…”

“…[13][14][15][16][17]19,20 Additionally, lower post-operative complications and shorter stay is also reported for EVAR both in RCT and administrative registries. [15][16][17][18][19] For this reason, it is difficult to draw definite conclusions. This inconsistency might be explained by selection bias more likely to occur in retrospective studies as most operators select patients both for EVAR or OR based on aortic morphology and hemodynamic stability.…”

“…Data from the US and Sweden registries show lower mortality rates for EVAR when compared to OR. 17,19,20 These studies provide results from a large number of patients, deriving from multiple vascular centers, reflecting daily practice over a long time period nationwide. Still, detailed patient characteristics which are essential elements for direct comparison between EVAR and OR are scarcely available.…”