Invited commentary

Abstract

Whereas the early mortality benefit of endovascular aneurysm repair (EVAR) over open repair for intact abdominal aortic aneurysms (AAAs) has been confirmed in numerous randomized trials and observational studies, the data regarding outcomes after repair of ruptured AAAs (rAAAs) are conflicting. As summarized in a recent Cochrane review, four randomized controlled trials failed to demonstrate improved short-term mortality after EVAR for rAAA.1Badger S. Forster R. Blair P.H. Ellis P. Kee F. Harkin D.W. Endovascular treatment for ruptured abdominal aortic aneurysm.Cochrane Database Syst Rev. 2017; 5: CD005261PubMed Google Scholar However, these trials were limited by small sample size, inclusion criteria leading to the exclusion of many patients, and frequent treatment variation from randomization. In this issue of the Journal of Vascular Surgery, Gupta et al add to the growing body of literature supporting EVAR for rAAA. Their analysis of a retrospective cohort from a national administrative database demonstrates lower in-hospital mortality after EVAR compared with open repair. EVAR was also associated with a lower frequency of major complications. These results are consistent with previously published observational studies that suggest an advantage to EVAR. In a retrospective cohort of Medicare beneficiaries, we identified a decrease in overall perioperative mortality for rAAA repair from 1995 to 2008, largely driven by increasing use of EVAR and its association with lower perioperative mortality.2Schermerhorn M.L. Bensley R.P. Giles K.A. Hurks R. O'Malley A.J. Cotterill P. et al.Changes in abdominal aortic aneurysm rupture and short-term mortality, 1995-2008: a retrospective observational study.Ann Surg. 2012; 256: 651-658Crossref PubMed Scopus (161) Google Scholar In addition, as the authors illustrate in their discussion, their results closely resemble the 30-day mortality from the as-treated analysis of the Immediate Management of Patients with Rupture: Open Versus Endovascular Repair (IMPROVE) trial, suggesting that the conclusions of this trial may be limited by the intention-to-treat approach. Furthermore, newly published 3-year data from IMPROVE do demonstrate a survival advantage with EVAR. In patients in whom repair was started, the odds ratio for death after EVAR at 3 years was 0.62 (95% confidence interval, 0.43-0.88). EVAR also led to decreased cost and better quality of life compared with open repair.3IMPROVE Trial InvestigatorsComparative effectiveness of an endovascular strategy versus open repair for ruptured abdominal aortic aneurysm: 3-year results of the IMPROVE randomised trial.Br Med J. 2017; 359: j4859Crossref PubMed Scopus (113) Google Scholar With their paper in this issue of JVS, Gupta et al further the argument that EVAR is superior to open repair for the treatment of rAAA. The selection of treatment modality for rAAA remains complex and will continue to depend on demographics of the patient, anatomic factors, hospital facilities, and experience of the surgeon.4Meltzer A.J. Connolly P.H. Schneider D.B. Sedrakyan A. Impact of surgeon and hospital experience on outcomes of abdominal aortic aneurysm repair in New York State.J Vasc Surg. 2017; 66: 728-734.e2Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar However, based on the results of both randomized trials and observation studies, we advocate for an endovascular-first approach. All patients with rAAAs should be treated in a hybrid operating room when one is available under local anesthesia, at least initially, with an aortic occlusion balloon available as needed for both EVAR and open repair. If the anatomy is suitable and appropriate endografts are available, percutaneous EVAR is our preferred treatment modality. However, open repair will continue to be necessary in certain circumstances, and surgeons must be prepared. In addition, decompressive laparotomy may be indicated despite successful EVAR, particularly when an aortic occlusion balloon is needed. We believe that the current literature composed of both randomized trials and observational studies supports this approach. Furthermore, as aortic stent grafts continue to improve and experience with EVAR expands, the advantage of EVAR in the treatment of rAAA is likely to continue to grow. The opinions or views expressed in this commentary are those of the authors and do not necessarily reflect the opinions or recommendations of the Journal of Vascular Surgery or the Society for Vascular Surgery. Real-world evidence of superiority of endovascular repair in treating ruptured abdominal aortic aneurysmJournal of Vascular SurgeryVol. 68Issue 1PreviewThe majority of previous studies, including randomized controlled trials, have failed to provide sufficient evidence of superiority of endovascular aneurysm repair (EVAR) over open aortic repair (OAR) of ruptured abdominal aortic aneurysm (rAAA) while comparing mortality and complications. This is in part due to small study size, patient selection bias, scarce adjustment for essential variables, single insurance type, or selection of only older patients. This study aimed to provide real-world, contemporary, comprehensive, and robust evidence on mortality of EVAR vs OAR of rAAA. Full-Text PDF Open Archive