A Greek Multicentre Study Assessing the Outcome of Late Rupture After Endovascular Abdominal Aortic Aneurysm Repair

Abstract

Late rupture after endovascular aortic aneurysm repair (EVAR) for an abdominal aortic aneurysm (AAA) is an increasing complication associated with high mortality. This study aimed to analyse the causes and outcomes in patients with AAA rupture after EVAR. A multi-institutional Greek study of late ruptures after EVAR between 2008 - 2022 was performed. Primary outcomes were intra-operative and in hospital mortality. A total of 70 patients presented with late rupture after EVAR (proportion of ruptured EVARs among all EVARs, 0.6%; 69 males; mean age 77.2 ± 6.7 years). The mean time interval between EVAR and late rupture was 72.3 months (range 6 - 180 months). In all cases the cause of rupture was the presence of endoleak (type I, 73%) with sac enlargement. Moreover, 34% of subjects with rupture after EVAR were lost to follow up and 32% underwent a secondary intervention. Additionally, 57 patients (81%) were treated with conversion to open surgical repair (COSR) and the remainder with endovascular correction of endoleak (ECE). Eleven intra-operative deaths (16%) were recorded. The overall in hospital mortality rate was 41% (23% ECE vs. 46% COSR; p = .21). Of the patients who presented as initially haemodynamically stable, 23% died during hospitalisation, while the respective mortality rate for patients who presented as unstable was 78% (odds ratio [OR] 11.8, 95% confidence interval [CI] 3.6 - 39.1; p < .001). Multivariate logistic regression analysis revealed that severity of haemodynamic shock was the most significant risk factor for intra-operative death (OR 7.15, 95% CI 1.58 - 32.40; p = .010) and in hospital mortality (OR 9.53, 95% CI 2.79 - 32.58; p < .001). These data underline the devastating prognosis of late rupture after EVAR. Haemodynamic status at presentation was an important predictive factor for mortality both in the ECE and COSR groups. Rigorous follow up and prompt evaluation of an unstable patient in case of rupture after EVAR is recommended.