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Complete Replacement of Open Repair for Ruptured Abdominal Aortic Aneurysms by Endovascular Aneurysm Repair: A Two-Center 14-Year Experience

Mayer, D. MD*; Aeschbacher, S.*; Pfammatter, T. MD*; Veith, F. J. MD; Norgren, L. MD, PhD§; Magnuson, A. BSc; Rancic, Z. MD, PhD*; Lachat, M. MD*; Larzon, T. MD

Annals of Surgery:
doi: 10.1097/SLA.0b013e318271cebd
Original Articles From the ESA Proceedings
Abstract

Objective: To present the combined 14-year experience of 2 university centers performing endovascular aneurysm repair (EVAR) on 100% of noninfected ruptured abdominal aortic aneurysms (RAAA) over the last 32 months.

Background: Endovascular aneurysm repair for RAAA feasibility is reported to be 20% to 50%, and EVAR for RAAA has been reported to have better outcomes than open repair.

Methods: We retrospectively analyzed prospectively gathered data on 473 consecutive RAAA patients (Zurich, 295; Örebro, 178) from January 1, 1998, to December 31, 2011, treated by an “EVAR-whenever-possible” approach until April 2009 (EVAR/OPEN period) and thereafter according to a “100% EVAR” approach (EVAR-ONLY period).

Straightforward cases were treated by standard EVAR. More complex RAAA were managed during EVAR-ONLY with adjunctive procedures in 17 of 70 patients (24%): chimney, 3; open iliac debranching, 1; coiling, 8; onyx, 3; and chimney plus onyx, 2.

Results: Since May 2009, all RAAA but one have been treated by EVAR (Zurich, 31; Örebro, 39); 30-day mortality for EVAR-ONLY was 24% (17 of 70). Total cohort mortality (including medically treated patients) for EVAR/OPEN was 32.8% (131 of 400) compared with 27.4% (20 of 73) for EVAR-ONLY (P = 0.376). During EVAR/OPEN, 10% (39 of 400) of patients were treated medically compared with 4% (3 of 73) of patients during EVAR-ONLY. In EVAR/OPEN, open repair showed a statistically significant association with 30-day mortality (adjusted odds ratio [OR] = 3.3; 95% confidence interval [CI], 1.4–7.5; P = 0.004). For patients with no abdominal decompression, there was a higher mortality with open repair than EVAR (adjusted OR = 5.6; 95% CI, 1.9–16.7). In patients with abdominal decompression by laparotomy, there was no difference in mortality (adjusted OR = 1.1; 95% CI, 0.3–3.7).

Conclusions: The “EVAR-ONLY” approach has allowed EVAR treatment of nearly all incoming RAAA with low mortality and turndown rates. Although the observed association of a higher EVAR mortality with abdominal decompression needs further study, our results support superiority and more widespread adoption of EVAR for the treatment of RAAA.

In Brief

Evolution of endovascular skills and adoption of adjunctive procedures eliminated the need for open repair of ruptured abdominal aortic aneurysms for the past 32 months. Overall mortality was 24%, despite a 96% treatment rate.

Author Information

*Clinic for Cardiovascular Surgery, University Hospital of Zurich, Zurich, Switzerland

The Cleveland Clinic and New York University Medical Center, New York

Department of Cardio-Thoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden

§Department of Surgery, Örebro University Hospital, Örebro, Sweden

Clinical Epidemiology and Biostatistic Unit, Örebro University Hospital, Örebro, Sweden.

Reprints will not be available from the authors.

There were no outside sources of support.

Disclosure: The authors declare no conflicts of interest.

© 2012 Lippincott Williams & Wilkins, Inc.