Collected World and Single Center Experience with Endovascular Treatment of Ruptured Abdominal Aortic Aneurysms

Abstract

Conclusion: In some patients, endovascular repair of ruptured abdominal aortic aneurysms (AAAs) has a lower procedural mortality at 30 days. Summary: Endovascular aneurysm repair (EVAR) for ruptured AAA was first reported in the mid-1990s (Ann Surg 1995;222:449-65 and Lancet 1994;344:1645). Since then, EVAR for ruptured AAAs has been reported with varying results. Some authors have concluded that EVAR results in improved survival in patients with ruptured AAA, but others have reported no better results with EVAR than traditional repair. Also, historic controls of open repair results are often used to compare with modern results of EVAR. All reports are case-series. There are no randomized trials comparing EVAR and open repair in patients with similar anatomy and hemodynamic stability. This article represents an attempt by the authors to summarize the literature with respect to endovascular treatment of ruptured AAAs. The authors examined a collective experience with use of EVAR to treat ruptured AAAs from 49 centers. Each center provided data in the form of answers to a questionnaire; in addition, a separate analysis was performed from 13 centers committed to EVAR treatment for ruptured AAA whenever possible. Information was obtained on 1037 patients treated by EVAR and 763 patients treated by open repair. In the 13 centers performing EVAR for ruptured AAA whenever possible, EVAR was actually performed in a mean of 49.1% of patients (range, 28%-79%). The 30-day mortality in 680 patients treated with EVAR for ruptured AAA in these centers was 19.7% (range, 0%-32%). The 30-day mortality of the 763 patients treated with open repair was 36.3% (range, 8%-53%; P < 0.0001). Of the 1037 patients treated with EVAR for ruptured AAA, 30-day mortality was 21.2%. In the 13 centers using EVAR whenever possible, supraceliac aortic balloon control was obtained in 19.1% ± 12%. An abdominal compartment syndrome was treated by some form of decompression in 12.2% ± 8.3%. Comment: One cannot argue with the conclusion EVAR has a lower procedural mortality in “at least some patients” and may be preferable for treating ruptured AAAs “provided that they (patients) have favorable anatomy; and adequate skills, facilities, and protocols are available, and optimal strategies, techniques, and adjuncts are employed.” This is a classic “mom and apple pie statement.” Whether or not it is correct or incorrect is actually relatively unimportant. For the foreseeable future, individual surgeons will need to make individual decisions for the treatment of ruptured AAA in individual patients. I do not agree with Dr Veith that performing a randomized trial of open vs EVAR for treatment of matched patients with ruptured AAA would be like performing a randomized trial on the use of parachutes. I do agree with Dr Veith that such a trial would be difficult to perform and that the performance of such a trial that provided results convincing to all would be nearly impossible.