PC044. Revisiting Endovascular Repair for Ruptured Abdominal Aortic Aneurysms

Abstract

The management of ruptured abdominal aortic aneurysms (AAAs) has changed over the past several years. There have been numerous studies that have shown conflicting results for the role of endovascular aortic aneurysm repair (EVAR) in ruptured AAA. There has been a mortality benefit in many studies, but it has been thought that the benefit is due to patient selection factors. However, unlike conventional surgical procedures, instrumentation for endovascular intervention, such as access catheters, wires and grafts, is improved constantly by industry. In light of this, we have compared the outcomes from EVAR with those of open repair. We analyzed data from 4133 patients with ruptured AAA treated with open surgery vs EVAR collected from the National Surgical Quality Improvement Program database from 2010 to 2016 using International Classification of Disease, 9th edition and 10th edition, as well as Current Procedural Terminology codes. We used χ2 tests and t tests to compare perioperative mortality between open and endovascular procedures. Logistic regression analysis was then used to correct for preoperative comorbidities. Analysis of strength of our model was performed using Hosmer-Lemeshow goodness-of-fit testing and receiver operator characteristic analysis. The number of endovascular cases in ruptured AAA increased from 30.1% in 2010 and peaked in 2015 at 53.7% (P < .001). Yearly operative mortality ranged from 27.3% to 39.2% in the open group and 18.1% to 26.2% in the EVAR group. Overall mortality was 22.6% for EVAR and 33.2% for open repair (P < .001). After adjusting for comorbidities, there was a 39% reduction in perioperative mortality with EVAR vs open repair (adjusted odds ratio [aOR], 0.61; 95% confidence interval [CI], 0.52-0.71; P < .001). Perioperative mortality in ruptured AAA was 46% greater in women as compared with men (aOR, 1.46; 95% CI, 1.23-1.73; P < .001), there was no difference between the EVAR and open groups. In addition, smoking status (aOR, 1.67; 95% CI, 1.43-1.95; P < .001), ventilator dependence (aOR, 3.69; 95% CI, 2.94-4.63; P < .001), preoperative transfusion of 1 or more units of packed red blood cells (aOR, 1.64; 95% CI, 1.40-1.96; P < .001), and functional status before surgery (aOR, 1.21; 95% CI, 1.14-1.29; P < .001) all had a statistically significant impact on perioperative mortality. EVAR is becoming an increasingly popular strategy for the treatment of AAA. As surgeon experience has increased, a greater percentage of ruptured AAA are being treated by EVAR. Retrospective analysis of outcomes from a national database portends a significant benefit even after adjustment for patient factors, to managing AAA with EVAR versus open surgery.