The endovascular management of ruptured abdominal aortic aneurysms

Abstract

Endovascular aneurysm repair (EVAR) is a controversial technique, which remains the subject of a number of prospective randomised trials. Although questions remain regarding its long-term durability objective evidence exists which demonstrates its reduced physiological impact compared with conventional open repair. If this technique could be used in patients with ruptured abdominal aortic aneurysm (AAA) it may reduce the high peri-operative mortality. A review of the literature identified a limited experience with EVAR of ruptured AAA. Only a small number of case series with selected patients exist. The majority of patients were haemodynamically stable. However, the selective use of aortic occlusion balloons allowed successful endovascular management in a small number of unstable cases. All investigators had access to an "off the shelf" endovascular stent-graft (EVG). Per-operative mortality ranged from 9 to 45% and may reflect increasing experience and patient selection. A number of patients who underwent successful EVAR were turned down for open repair. A number of important lessons have been learned from these studies but questions remain regarding patient suitability and staffing issues. If these difficulties can be surmounted then the technique may offer an alternative to open repair.

Mortality After Endovascular Repair of Ruptured Abdominal Aortic Aneurysms

“…Of these, 7 articles were excluded because they were reviews or invited commentaries, 39,41,44,[48][49][50][51] 7 because they were series from the same institutions with duplicate clinical material, [36][37][38]40,42,45,46 1 because it was a study on octogenarians, 43 and 2 because they were single-case reports. 6,47 This left 29 studies for analysis, reporting on a total of 897 patients.…”

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

“…Few cases demonstrate the successful use of EVAR in hemodynamically unstable AAA. In cases like ours where patients represent high surgical mortality risk, EVAR may be a useful alternative [3][4][5][6][7][8][9][10][11][12][13]16,17,19,20]. We present our case as a piece of the growing evidence that EVAR may be useful in patients with a ruptured AAA that are also hemodynamically unstable.…”

“…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 addition, EVAR is associated with the development of endoleaks, which require repair.…”

“…In addition, EVAR is associated with the development of endoleaks, which require repair. Both of these potential complications require lifelong surveillance [1,4,[6][7]10,13].…”