Mortality After Endovascular Repair of Ruptured Abdominal Aortic Aneurysms

Abstract

Objective: To document mortality after endovascular repair of ruptured abdominal aortic aneurysms (RAAAs).Data Sources: MEDLINE and EMBASE databases.Study Selection: Articles that reported data on mortality after endovascular repair of RAAAs were identified. Only patients with true ruptures were included. Additionally, information on mortality after concurrent open repair was sought.Data Extraction: One of the authors reviewed all of the studies and extracted appropriate data. A total of 43 articles were identified, 14 of which were excluded.Data Synthesis: Twenty-nine articles with 897 patients who underwent endovascular repair met the inclusion criteria. Of the patients with available information, 86% were men; 29% had been operated on under local anesthesia; 28% were hemodynamically unstable; 17% required intra-aortic balloon occlusion; 48% received bifurcated stent grafts; 6% had endovascular procedures converted to open repair intraoperatively; and 5.5% developed abdominal compartment syndrome. Inhospital and/or 30-day mortality ranged between 0% and 54% in different series, whereas the pooled mortality after endovascular repair was 24.5% (95% confidence interval [CI], 19.8%-29.4%). In 19 studies reporting results of both endovascular and concurrent open repair from the same unit, the pooled mortality after open repair was 44.4% (95% CI, 40.0%-48.8%), and the pooled overall mortality for RAAA undergoing endovascular or open repair was 35% (95% CI, 30%-41%).Conclusions: Endovascular repair of RAAAs is associated with acceptable mortality rates. Additional studies will be required to verify these promising results and precisely define the role of endovascular treatment as an additional therapeutic option for RAAAs.

Successful use of emergent endovascular aneurysm repair for a ruptured hypotensive abdominal aortic aneurysm

“…The use of EVAR for abdominal aortic aneurysm offers the potential advantage of avoiding the complications associated with a large abdominal surgical incision, avoiding the stress on organs and tissues induced by the need to cross clamp the aorta, decreasing bleeding and inflammatory response from surgical tissue dissection, reducing risk of multiorgan failure, lessening the requirement for deep anesthesia, and providing a repair mechanism for patients who are too high risk for open repair surgical procedures due to cardiac risk factors or other comorbidity [1,[5][6][7][8][9][11][12][13]. Endovascular aneurysm repair also offers the benefit of shorter hospital stays, reduced recovery time, less post-procedural pain, and avoids the complication of adhesive intestinal obstruction when compared to open repair [1,[4][5][6][7][8][9].…”

“…Endovascular aneurysm repair also offers the benefit of shorter hospital stays, reduced recovery time, less post-procedural pain, and avoids the complication of adhesive intestinal obstruction when compared to open repair [1,[4][5][6][7][8][9]. However, a negative aspect for EVAR is the possibility of graft movement after treatment that could allow reinstatement of the aneurysm [1,4,10,13].…”

“…In patients with ruptured AAA, EVAR appears to offer a decreased operative mortality [1,[5][6][7][8][9][10]. Unfortunately, this information is derived from retrospective studies or case series with little randomized prospective data available, and the available studies may not adequately adjust for selection bias [4,[6][7][8][9][10]14,15].…”

“…In patients with ruptured AAA, EVAR appears to offer a decreased operative mortality [1,[5][6][7][8][9][10]. Unfortunately, this information is derived from retrospective studies or case series with little randomized prospective data available, and the available studies may not adequately adjust for selection bias [4,[6][7][8][9][10]14,15]. There is a tendency for more severely unstable patients requiring a faster treatment decision to undergo traditional open repair, and because circulatory shock is a significant prognostic factor, this has been suggested to falsely improve the favorable EVAR results [1,2,4,[6][7][8][9][10][16][17][18].…”

“…Unfortunately, this information is derived from retrospective studies or case series with little randomized prospective data available, and the available studies may not adequately adjust for selection bias [4,[6][7][8][9][10]14,15]. There is a tendency for more severely unstable patients requiring a faster treatment decision to undergo traditional open repair, and because circulatory shock is a significant prognostic factor, this has been suggested to falsely improve the favorable EVAR results [1,2,4,[6][7][8][9][10][16][17][18]. However, in the available reported literature, patients who undergo EVAR for ruptured AAA tend to have greater co-morbidities and risk factors than those who are given open repair, and have a greater time delay to treatment due to CT scanning to confirm rupture [1,10,11,15,18].…”