The Impact of Centralization and Endovascular Aortic Repair on Treatment of Ruptured Abdominal Aortic Aneurysms Based on International Registries

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Introduction - Endovascular aortic repair (EVAR) is the predominant treatment modality for treatment of intact abdominal aortic aneurysms (AAA) in many countries, and its use is also increasing in cases of ruptured AAAs (RAAA).1 Variation in AAA treatment between and within countries influences outcomes of intact AAAs, but little is known on the recent trends and outcomes in RAAA treatment.2 The objective of this analysis was to update recent treatment strategies and outcomes from the Vascunet registry, an international collaboration of vascular surgery registries. Methods - An analysis of all RAAAs from vascular surgical registries in eleven countries from 2010-2013 was carried out. Data were analysed overall, per country, per treatment (EVAR vs. open aortic repair (OAR)), for the volume per centre, divided into quintiles (QI-V), and for centres that were either predominantly EVAR (>50% of rAAA repairs performed with EVAR; pEVAR) or predominantly OAR (pOAR). The primary outcome was perioperative mortality, defined depending on which registry, as either in-hospital or death within 30 days after repair. Data are presented as percentages with 95% confidence intervals (CI), and compared with Chi-square test. Results - There were 9273 patients included. These represented 16.0% (15.7-16.3) of the total number of AAAs operated in this period, ranging from 10.3% (9.8-11.8) in Germany to 29.4% (25.9-32.9) in Finland. The mean age was 74.7 (74.5-74.9), and the majority were men (82.7%, CI, 81.9-83.6). The mean AAA size at the time of rupture was 7.6 cm (7.5-7.6). The perioperative mortality was 28.8% (27.9-29.8), 32.3% (29.9-34.9) for women, greater than for men, 27.1% (26.1-28.2), p <0.001. Perioperative mortality was 32.1% (31.0-33.2) for OAR and 17.9% (16.3-19.6) for EVAR, p<0.001. Perioperative mortality was lower in the highest volume centres (QI, > 22 repairs per year), 23.3% (21.2-25.4), p<0.001. The highest volume centers were also performing the greatest percentage of OAR, 85.6% (83.9-87.4), p<0.001, and all high volume centers (n=13) were pOAR. Perioperative mortality was lower in pEVAR centres (23.0%, 95% CI: 20.6-25.4) vs. pOAR centres (29.7%, 95% CI: 28.6-30.8), p<0.001. Perioperative mortality for OAR was significantly lower in the high volume centres, 25.3% (23.0-27.6), p<0.001. Conclusion - OAR still predominates as the treatment of choice for RAAA treatment, even in the highest volume centres, despite opposite time-trends in intact repair. Perioperative mortality is lower in centres either with high volumes or a predominant EVAR approach to treatment, while results are also better for OAR at centres of high volume. It must be emphasized, however, that this investigation only has reported on those operated on for RAAA. Centralization and EVAR availability favour outcome of those operated on, but there is also a need to study those not offered repair.