Endovascular Repair of Ruptured Abdominal Aortic Aneurysms in a Rural Center Is Both Feasible and Associated with Reduced Blood Product Requirements

Abstract

Endovascular aneurysm repair (EVAR) of ruptured abdominal aortic aneurysm (rAAA) has been shown to be both feasible and associated with a reduced operative mortality when compared with conventional open repair (OR). The aim of this study was to show the feasibility of EVAR of rAAA in a rural vascular unit and to investigate the blood product requirements when compared to OR. The method used in this study was a retrospective case note review of patients presenting with rAAA to a small, rural vascular unit between February 2004 and November 2008. Admission demographics and hematological variables were recorded. Volumes of crystalloid, colloid and blood products were recorded prior to intensive care unit (ICU) admission and for the first 48 hours following ICU admission. Results are expressed as medians and Mann-Whitney U test was used to compare variables. Of 81 patients presenting with rAAA, 36 were treated palliatively. Of 45 patients who underwent intervention, 7 had EVAR and all survived to discharge (0% operative mortality). Of 38 who had OR, 16 died before discharge for an operative mortality of 42%, 36% if the EVAR patients are included. Admission demographics and hematological variables of patients who had EVAR, patients who had OR and survived (ORS) and patients who had OR and died (ORD) showed no significant difference. When compared with ORS patients, those undergoing EVAR had significantly less pre-ICU crystalloid (3 L vs 7.5 L, p = .001), less red blood cell transfusion (1 unit vs 6.5 units, p = .0006), and less colloid (0 L vs 0.5 L, p = .008). When compared with ORD, those undergoing EVAR had less red blood cell transfusion (1 unit vs 7 units, p = .0001) and less fresh frozen plasma (0 units vs 4 units, p = .03). Within the first 48 hours of admission to ICU, the blood product requirements were no different in those undergoing EVAR when compared with OR. EVAR of rAAA is feasible in a small rural vascular unit and appears to be associated with reduced requirements for blood products.

The Impact of Blood Component Transfusion Practices on Patient Survival After Abdominal Aortic Aneurysm Surgery

“…Further improvement is to be expected with the introduction of EVAR even in cases of ruptured AAA with use of a transfemoral aortic balloon catheter to stop the bleeding. 21,22 Finally, goal-directed transfusion therapy guided by thromboelastograhpy is likely the optimal solution instead of transfusion with fixed FFP/RBC ratio. 6,23…”

Association between sex and perioperative mortality following endovascular repair for ruptured abdominal aortic aneurysms

“…There were 22 nonresponders and eight authors with failing contact addresses. Ultimately, information on data stratified by sex was available from 13 studies, [11][12][13][14][15][16][17][18][19][20][21][22][23] while 15 were excluded as they were duplicated reports by the same institution or authors. [2][3][4][24][25][26][27][28][29][30][31][32][33][34][35] Personal contribution with 32 rAAA treated at the principal investigator's center (Perugia, Italy) were additionally pooled with those retrieved by the literature for a total of 14 articles providing information on EVAR for rAAA in women and men for the present review.…”

“…None of the studies were randomized, but for one single-center study, a small number of patients enrolled in a randomized trial on rAAA were included with outsidetrial patients. 21 There were 11 single-center case series (including authors' personal experience), 11,13,[15][16][17][18][19][21][22][23] seven retrospective, 11,[16][17][18][19]22,23 and four prospective studies 13,15,17,21 with variable range of patients and women percentages. Most included small numbers, with only four collecting 30 or more cases.…”

“…Additional analyses were conducted according to study size, separating those including at least 10 women [12][13][14][20][21][22] (and mainly based on U.S. population databases 12,14,20 ) from those with smaller female population. 11,[15][16][17][18][19]23 Mortality rates were comparable between sex categories in both study subgroups. For the subgroup of six studies with large female population (>10), there were 466/ 1308 perioperative mortality events (pooled rate, 35.8%) in women and 1297/4065 in men (pooled rate, 32.0%): pooled OR, 1.23 (95% CI, 0.92-1.65; P ¼ .16).…”

“…Pooled analyses in the large female population subgroup of studies were repeated after the exclusion of the Medicare database 14 report: the pooled OR in women vs men was 1.19 (95% CI, 0.68-2.09; P ¼ .54). In the subgroup of studies with a population of less than 10 women (including personal experience), 11,[15][16][17][18][19]23 perioperative mortality occurred in 7/31 women (pooled rate, 24.3%) and 37/ 176 men (pooled rate, 22.8%) without a significant increase in mortality risk for women (pooled OR, 1.19; 95% CI, 0.46-3.09).…”