Long-term outcomes following exclusive use of endovascular aortic repair for ruptured infrarenal abdominal aortic aneurysms : Chinese Medical Journal

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Long-term outcomes following exclusive use of endovascular aortic repair for ruptured infrarenal abdominal aortic aneurysms

Wang, Ruihan1,2,3; Yuan, Tong1,2,3; Kan, Yuanqing1,2,3; Yue, Jianing1,2,3; Chen, Bin1,2,3; Dong, Zhihui1,2,3; Guo, Daqiao1,2,3; Si, Yi1,2,3; Fu, Weiguo1,2,3

Editor(s): Pan, Xiangxiang; Wei, Peifang

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Chinese Medical Journal ():10.1097/CM9.0000000000002534, May 23, 2023. | DOI: 10.1097/CM9.0000000000002534

To the Editor: Ruptured abdominal aortic aneurysm (rAAA) is a fatal disease. Emergency surgery is the only way to provide an opportunity for survival. In 1994, endovascular aortic repair (EVAR) was reported as an emergency treatment for rAAA. Compared with traditional open surgery (OS), patients could benefit from its lower perioperative mortality and minimal invasiveness. Although recent guidelines have recommended an EVAR-first approach if suitable as judged by the clinician, the standard of whether to give a priority to EVAR varies among clinicians in practical applications, because hostile aortic morphology and hemodynamic conditions were thought to weaken the benefit of EVAR. Hence, controversies still exist regarding whether EVAR as a priority is applicable to most rAAAs. In addition, a search of the literature found few population-based studies with long-term outcomes. Given this, a population-based study was conducted by Zhongshan Hospital, Fudan University.

Since 2010, our center has experimentally adopted EVAR as the priority approach for patients presenting with infrarenal rAAAs based on the modified indications for EVAR, and has not conducted any open repair surgeries [Supplementary Table 1, https://links.lww.com/CM9/B439]. We modified the requirements of hemodynamic and anatomical conditions to ensure that EVAR can be conducted in a timely manner to restore blood flow. Ethical approval of this study was obtained from the Committee for the Protection of Human Subjects at Zhongshan Hospital, Fudan University (No. B2021-216). Informed consent was obtained from all patients or their family members before the operation.

The patients were divided into four subgroups: Group 1: favorable aortic anatomy (proximal neck length >15 mm, infrarenal proximal angulation < 45 and minimum aortic diameter at renal artery level <28 mm) +stable hemodynamics; Group 2: favorable aortic anatomy+unstable hemodynamics (systolic blood pressure <80 mmHg or shock with systolic blood pressure <50 mmHg or organ hypoperfusion at admission); Group 3: hostile aortic anatomy (proximal neck length <15 mm, infrarenal proximal angulation >45 or minimum aortic diameter at renal artery level >28 mm) +stable hemodynamics; Group 4: hostile aortic anatomy+unstable hemodynamics. The patients were followed up by computed tomographic angiography (CTA) at 3, 6, 12 months, and yearly thereafter. Demographics, length of stay, 24-hour, in-hospital, 30-day, 1, 3, and 5-year mortality after surgery were recorded. Additional data included stent-related complications, additional interventions, detailed surgery records, and follow-up CTA. The final follow-up time was December 2020. Our primary outcomes were peri-operative, short-term, and mid-to-long-term mortality. Secondary outcomes included reintervention and stent-related complications.

Categorical variables are presented as frequencies with percentages. Comparison between categorical variables was performed with the χ2 test or Fisher's exact test according to the sample size. Continuous variables are presented as mean ± standard deviation or median (Q1, Q3). One-way analysis of variance (ANOVA) test, Welch's ANOVA test or non-parametric test was used for the analysis, as appropriate. The survival data were analyzed by Kaplan–Meier analysis and the log-rank test. A P value < 0.05 was considered statistically significant. Statistical analyses were performed using SPSS 22.0 (IBM Corp, Armonk, NY, USA).

From January 2010 to September 2017, 57 patients received EVAR for infrarenal rAAA. The time from admission to EVAR was 53 ± 12 min. All patients underwent EVAR in accordance with the unified treatment scheme.[1] The median follow-up time was 60.2 months, and the longest follow-up was 119.2 months. The median length of hospital stay was 11.0 days (7.8–22.3 days). The 24-hour mortality rate was 3.5% (2/57). The in-hospital mortality rate was 12.3% (7/57). The 30-day mortality rate was 18.4%. The 1-year mortality rate was 32.3%. The short-term mortality rates were in line with the existing studies.[2] The long-term mortality rates were 46.5% (3 years) and 60.0% (5 years) [Figure 1A]. At the end of the study, among patients with complete follow-up information 11 patients survived >5 years after EVAR, and they were considered to have a long-term survival benefit. We compared the survival rates of the Group 2 and 3 with that of the Group 1 and did not observe statistically significant differences (log-rank test, P1 = 0.827, P2 = 0.641, [Figure 1B]). The results suggested that compared with patients with favorable aortic anatomy and stable hemodynamics, EVAR may also provide survival benefits for rAAA patients with unstable hemodynamics or hostile aortic anatomies. There were only five patients in subgroup 4. One patient died during hospitalization. One patient survived for >5 years and did not undergo reintervention. One patient died of hemorrhagic shock caused by rerupture at 14.1 months. One patient was admitted to our center with pneumonia at 37.5 months and died of severe septic shock. The remaining patient developed a fever at 50.2 months, and was diagnosed with type Ib endoleak and died of MODS. The characteristics of patients in four group were presented in Supplementary Table 2, https://links.lww.com/CM9/B439, and there were no significant statistical differences among the groups.

Figure 1:
(A) Kaplan–Meier curves of all patients who underwent EVAR as the priority approach for infrarenal rAAAs. (B) Kaplan–Meier curves of different subgroups show that there were no significant differences among the subgroup with ideal aortic morphology and stable hemodynamics (Group 1), the subgroup with favorable aortic anatomy and unstable hemodynamics (Group 2), and the subgroup with hostile aortic anatomy and stable hemodynamics (Group 3). EVAR: Endovascular aortic repair; rAAA: Ruptured abdominal aortic aneurysm.

A total of 13 patients had immediate endoleaks (22.8%, 13/57), including 10 (17.5%, 10/57) type Ia, 2 (3.5%, 2/57) type Ib, and 1 (1.8%, 1/57) type Ib and III. Three patients with type Ia endoleaks were treated by the proximal cuff technique. The other seven patients with type Ia endoleaks were follow-up closely because the endoleaks detected is slight; from their follow-up CTA, the endoleak in two patients disappeared at 1 year, in four patients disappeared at 2 years, and only one patient had persistent leakage but without further enlargement (during 3-year follow-up: the diameter of the aorta increased by <5 mm). Two patients with type Ib endoleaks disappeared after management by balloon dilation. The patient with type Ib and type III endoleaks was managed by relining. Among the 15 patients in Group 3, 5 (33.3%, 5/15) had immediate endoleaks. There was no significant difference in the incidence of immediate endoleaks among Group 1 (23.1%, 6/26), Group 2 (14.3%, 2/14), and Group 3 (33.3%, 5/15) (P = 0.689). All of the endoleaks were followed up closely. These immediate endoleaks did not affect the technical safety of the EVAR, and the follow-up CTA did not show further enlargement.

In recent years, there are controversies surrounding the choice of optimal procedure for rAAAs. The choice between OS and EVAR is mainly based on operator preference and patient characteristics. Here, we reported the results based on clinical practice that set EVAR as a priority choice with a long-term follow-up. Our study found lower 24-hour and in-hospital mortality than other existing studies, and the 30-day, 1-year, and 3-year mortality rates were in line with the existing studies.[2] In Kontopodis et al's[3] meta-analysis, they comprehensively demonstrated that EVAR had a lower peri-operative mortality rate than OS, and our results also demonstrated that EVAR as the priority choice had a good short-term survival outcome. A lower 24-hour mortality rate could be observed in our study compared with previous study,[3] which may be related to our treatment scheme and the characteristics of EVAR itself: (1) We tried to adopt local anesthesia if possible, which had a lower effect on hemodynamic consequences in rAAA patients compared with general anesthesia,[4] and the potential benefit appears considerable. (2) Our center has a round-the-clock “fast pass” for rAAAs, which greatly shortens the rescue time. The peri-operative period was a vital time for survival; if EVAR could be performed, it is a better choice than OS from the perspective of reducing peri-operative mortality.

The impact of aortic morphology on prognosis is one of the key concerns of EVAR. For patients with hostile aortic anatomy, type Ia endoleak is a common and dangerous adverse event.[5] Besides, for the immediate management for patients with rupture, open versus endovascular repair study reported that endoleak was the most common cause for reintervention.[6] In the present study, EVAR also showed clinical benefits for rAAA patients with unfavorable anatomical conditions due to advances in technology and equipment. By means of increasing the oversizing rate appropriately, cuff and balloon dilatation, the most of endoleaks could be resolved. For patients with a short infrarenal neck, Endurant endograft, which was designed for a neck length limit to 10 mm and had good compliance with the hostile aortic neck, was used for the majority of our patients. According to the follow-up CTA results, most endoleaks disappeared after one year, and the persistent leakages did not cause further enlargement, suggesting that EVAR in patients with unfavorable aortic anatomy is technically feasible and safe in experienced centers.

As this is a single-center and single-arm clinical study, the sample size was small. And the patients with hostile aortic anatomy and unstable hemodynamics were not included in the final analysis to avoid a large deviation. In the future, more multicenter studies with larger sample sizes need to be conducted to confirm the results of the present study.

In conclusion, our current data demonstrated that EVAR for infrarenal rAAA should be more recommended in experienced centers. EVAR as a priority choice for infrarenal rAAA in institutions with professional could achieve low peri-operative mortality. The subgroup analysis indicated that EVAR for rAAAs with unstable hemodynamics or hostile aortic anatomy is technically safe in terms of the lower short-term mortality and undifferentiated long-term survival rate.


This work was financially supported by the National Natural Science Foundation of China (No. 8207021027), the Shanghai Clinical Research Center for Interventional Medicine (No. 19MC1910300), and the Shanghai Science and Technology Commission (Nos. 19441906600 and 21S31904800).

Conflicts of interest



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