Clinical Presentation, Operative Management, and Long-Term Outcome of Rupture After Previous Abdominal Aortic Aneurysm Repair

Abstract

Late abdominal aortic aneurysm rupture (LAR) after open or endovascular repair is uncommon but life-threatening. In the present study, we characterized the presentation trends, intervention, and survival after LAR. We performed a single-center, retrospective study of patients who had undergone LAR repair from 2000 to 2020. The endpoints were 30-day mortality, major postoperative complications, and survival. We compared the outcomes between LAR managed with endovascular aortic aneurysm repair (EVAR; group I) vs open surgical repair (OSR; group II). Of 390 patients with infrarenal aortic aneurysm rupture, 40 (10%) had undergone prior aortic repair and comprised the LAR cohort (34 men; mean age, 78 years; initial EVAR for 29; initial OSR for 11). LAR had occurred despite reintervention in 13 patients (44%). Endoleaks had developed in 26 patients and were type I in 21 patients (72%), type III in 3 patients, (10%) and type II in 2 patients (3%). Ten patients (29%) were lost to follow-up. LAR after prior OSR was secondary to ruptured para-anastomotic pseudoaneurysms, which were managed with endovascular salvage in nine patients. The time to LAR was shorter after prior EVAR compared with after OSR (6 ± 4 vs 12 ± 4 years, respectively; P = .003). Treatment of LAR was EVAR for 27 patients (67%; group I) and OSR for 14 (35%; group II). EVAR was more frequent in the latter one half of the study period (Fig). In group I, fenestrated repair had been used for seven patients (26%). Salvage for the rest was feasible with EVAR, aortic cuffs, or limb extensions. The incidence of free rupture, time to treatment, 30-day mortality, and disposition was similar between the two groups. Those in group I had had less blood loss (660 vs 3000 mL; P < .001) and need for dialysis (0% vs 33%; P < .001) than those in group II. The median follow-up was 20 months (interquartile range, 6-45 months). The 1-, 3-, and 5-year survival was 76%, 52%, and 41%, respectively, and was similar between the two groups (28 vs 22 months; P = .92). LAR after abdominal aortic aneurysm repair has become increasingly common, likely resulting from the frequency of EVAR. Most LARs, including those occurring after previous OSR, can be now be salvaged with endovascular techniques with lower morbidity and mortality.