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      Endovascular vs. Open Repair for Ruptured Abdominal Aortic Aneurysm

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          Abstract

          Background

          Patients presenting with ruptured abdominal aortic aneurysms are most often treated with open repair despite the fact that endovascular aneurysm repair is a less invasive and widely accepted method with clear benefits for elective aortic aneurysm patients. A debate exists regarding the definitive benefit in endovascular repair for patients with a ruptured abdominal aortic aneurysm. The aim of this literature review was to determine if any trends exist in favor of either open or endovascular repair.

          Material/Methods

          A literature search was performed using PUBMED, OVID, and Google Scholar databases. The search yielded 64 publications.

          Results

          Out of 64 publications, 25 were retrospective studies, 12 were population-based, 21 were prospective, 5 were the results of RCTs, and 1 was a case-series. Sixty-one studies reported on early mortality and provided data comparing endovascular repair (rEVAR) and open repair (rOR) for ruptured abdominal aneurysm groups. Twenty-nine of these studies reported that rEVAR has a lower early mortality rate. Late mortality after rEVAR compared to that of rOR was reported in 21 studies for a period of 3 to 60 months. Results of 61.9% of the studies found no difference in late mortality rates between these 2 groups. Thirty-nine publications reported on the incidence of complications. Approximately half of these publications support that the rEVAR group has a lower complication rate and the other half found no difference between the groups. Length of hospital stay has been reported to be shorter for rEVAR in most studies. Blood loss and need for transfusion of either red cells or fresh frozen plasma was consistently lower in the rEVAR group.

          Conclusions

          Differences between the included publications affect the outcomes. Randomized control trials have not been able to provide clear conclusions. rEVAR can now be considered a safe method of treating rAAA, and is at least equal to the well-established rOR method.

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          Most cited references86

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          Mortality from ruptured abdominal aortic aneurysms: clinical lessons from a comparison of outcomes in England and the USA.

          Alan Karthikesalingam, Peter Holt, Alberto Vidal-Diez … (2014)
          The outcome of patients with ruptured abdominal aortic aneurysm (rAAA) varies by country. Study of practice differences might allow the formulation of pathways to improve care.
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            Endovascular repair versus open repair of ruptured abdominal aortic aneurysms: a multicenter randomized controlled trial.

            Ron Balm, J. Reekers, … (2013)
            Randomized comparison of endovascular repair (EVAR) with open repair (OR) in patients with a ruptured abdominal aortic aneurysm (RAAA). Despite advances in operative technique and perioperative management RAAA remains fraught with a high rate of death and complications. Outcome may improve with a minimally invasive surgical technique: EVAR. All patients with a RAAA in the larger Amsterdam area were identified. Logistics for RAAA patients was changed with centralization of care in 3 trial centers. Patients both fit for EVAR and for OR were randomized to either of the treatments. Nonrandomized patients were followed in a prospective cohort. Primary endpoint of the study was the composite of death and severe complications at 30 days. Between April 2004 and February 2011, we identified 520 patients with a RAAA of which 116 could be randomized. The primary endpoint rate for EVAR was 42% and for OR was 47% [absolute risk reduction (ARR) = 5.4%; 95% confidence interval (CI): -13% to +23%]. The 30-day mortality was 21% in patients assigned to EVAR compared with 25% for OR (ARR = 4.4% 95% CI: -11% to +20%). The mortality of all surgically treated patients in the nonrandomized cohort was 30% (95% CI: 26%-35%) and 26% (95% CI: 20% to 32%) in patients with unfavorable anatomy for EVAR, treated by OR at trial centers. This trial did not show a significant difference in combined death and severe complications between EVAR and OR. Mortality for OR both in randomized patients and in cohort patients was lower than anticipated, which may be explained by optimization of logistics, preoperative CT imaging, and centralization of care in centers of expertise.
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              Management of ruptured abdominal aortic aneurysm in the endovascular era.

              Mark H Meissner, Carolyn Hutter, N. V. Tran … (2009)
              Our institution treats about 30 patients per year with ruptured abdominal aortic aneurysms (rAAA). Between 2002 and 2007, our 30-day mortality averaged 58%. In July 2007, we implemented an algorithm to promote endovascular aneurysm repair (EVAR) when feasible. This report describes the outcome with this approach. Data on patients presenting with rAAA between July 1, 2002, and June 30, 2007, were reviewed and used for comparison to prospectively collected data. Data on patients presenting between July 1, 2007, and April 30, 2009, were collected on all patients after implementation of a structured protocol. The primary outcome measure was 30-day mortality. Data were analyzed using logistic regression. Kaplan-Meier survival curves and a log-rank test were performed to compare survival times for three groups (pre-protocol, post-protocol with open surgery, and post-protocol with EVAR). During the study period, 187 patients with rAAA presented to our institution. Before implementation of the algorithm, 131 patients with rAAA presented and 128 were treated. The 30-day mortality rate was 57.8%. After implementation of the protocol, 56 patients with rAAA were managed. Twenty-seven patients (48%) underwent successful EVAR, and 24 patients (43%) underwent open repair. Five patients (9%) underwent comfort care only. In the post-protocol period, 5 patients in the EVAR group (18.5%) and 13 patients in the open group (54.2%) died during the follow-up period for an overall 30-day mortality rate of 35.3% (P = .008 vs 57.8% pre-protocol). After implementation of a structured protocol for managing rAAA, there was a relative risk reduction in 30-day mortality of 35% compared to the time before implementation of the protocol (95% confidence interval [CI], 14%-51%) corresponding to an absolute risk reduction of 22.5% (95% CI, 6.8%-38.2%) and an odds ratio of 0.40 (95% CI, 0.20-0.78; P = .007). After adjusting for key factors predicting mortality, the odds ratio is 0.25 (95% CI, 0.10-0.57; P = .001). Use of an algorithm favoring endovascular repair resulted in a highly significant reduction in rAAA mortality in our urban hospital. Thirty-day mortality for open repair was no different between pre- and post-protocol eras. With modern techniques of resuscitation and surgical management, a majority of patients presenting with rAAA can survive. Copyright 2010 Society for Vascular Surgery. All rights reserved.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Med Sci Monit Basic Res
                Journal ID (iso-abbrev): Med Sci Monit Basic Res
                Journal ID (publisher-id): Medical Science Monitor Basic Research
                Title: Medical Science Monitor Basic Research
                Publisher: International Scientific Literature, Inc.
                ISSN (Print): 2325-4394
                ISSN (Electronic): 2325-4416
                Publication date Collection: 2016
                Publication date (Electronic): 19 April 2016
                Volume: 22
                Pages: 34-44
                Affiliations
                [1 ]Vascular Unit, First Department of Surgery, Laiko General Hospital, Medical School, National & Kapodistrian University of Athens, Athens, Greece
                [2 ]Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, OH, U.S.A.
                Author notes
                Corresponding Author: Nikolaos Patelis, e-mail: patelisn@ 123456gmail.com
                [A]

                Study Design

                [B]

                Data Collection

                [C]

                Statistical Analysis

                [D]

                Data Interpretation

                [E]

                Manuscript Preparation

                [F]

                Literature Search

                [G]

                Funds Collection

                Article
                Publisher ID: 897601
                DOI: 10.12659/MSMBR.897601
                PMC ID: 4847558
                PubMed ID: 27090791
                SO-VID: a68ed364-35b8-4a96-9126-6fe538a4c9f8
                Copyright © © Med Sci Monit, 2016
                License:

                This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivs 3.0 Unported License

                History
                Date received : 15 January 2016
                Date accepted : 24 February 2016
                Categories
                Subject: Review Articles

                Keywords: aneurysm, ruptured,aortic aneurysm, abdominal,endovascular procedures
                Data availability:
                Keywords: aneurysm, ruptured, aortic aneurysm, abdominal, endovascular procedures

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