Open Versus Endovascular Repair Research Articles

Risk Factors for Development of Incisional Hernia after Aortic Aneurysm Repair: Secondary Analysis of the OVER Randomized Controlled Trial

Since the risk of mortality from rupture is elevated, elective repair of abdominal aortic aneurysms (AAAs) is often recommended. Currently, over 80% of elective repairs are carried out using an endovascular approach. While open repair has similar late survival and fewer reintervention outcomes when compared to endovascular repair, incisional hernia is a frequent complication with morbidity and cost implications. The Open versus Endovascular Repair (OVER) trial was the largest randomized trial of endovascular versus open repair of AAA in the United States. The purpose of this study was to determine risk factors associated with incisional hernia development following AAA repair via secondary analysis of the OVER data. This was a multisite trial conducted within the Veterans Affairs health-care system. Study participants (N=881) were enrolled from 2002 to 2008 and followed until 2011 with additional administrative data collection until 2016. Eligible patients had AAA for which elective repair was planned and randomized 1:1 to either open or endovascular repair. Incisional hernia was a prespecified end point in the OVER protocol, specifically assessed at each protocol follow-up visit. Technical details were extracted from each operative report, repair case report form(s), and adverse event form(s). Patient demographics, comorbid conditions, reported preoperative activity level, and operative details including initial approach, blood loss, and closure methods were analyzed using Bayesian hierarchical Weibull survival regression modeling. Incisional hernias were recorded among 46 participants (5.2%). The average time to hernia diagnosis was 3.5years. Of the 437 participants randomized to open treatment, 427 received an open repair including crossovers from endovascular treatment assignment. Transperitoneal repair was performed in 81%, running suture in 96%, and absorbable suture in 71% of cases. Randomization to endovascular repair was associated with reduced risk of hernia (hazard ratio [HR] 0.70, 95% credible interval [CI] 0.49-0.94). Higher activity level was associated with increased hernia risk (HR 1.39, 95% CI 1.06-1.84). Approach, suture closure techniques, body mass index, diabetes, and smoking status were not associated with increased risk of hernia development. Incisional hernia is a frequent complication associated with open repair of abdominal aortic aneurysm and commonly required reintervention. Endovascular repair was associated with reduced risk of hernia. Patients with increased activity experienced a higher incidence of hernia. However, no other modifiable patient, operative, or technical factors were found to be associated with hernia development.

Sex-stratified 5-Year Outcomes Following Endovascular Versus Open Repair of Complex Abdominal Aortic Aneurysms

Sex-stratified 5-Year Outcomes Following Endovascular Versus Open Repair of Complex Abdominal Aortic Aneurysms

Analysis of Repair Type and Hypogastric Artery Antegrade Perfusion and Erectile Function following Repair of Abdominal Aortic Aneurysms

Published reports suggest that exclusion of antegrade hypogastric artery flow may have deleterious effects on erectile function after abdominal aortic aneurysm (AAA) repair. Off-label and open surgical hybrid procedures and, more recently, purpose-built branched devices have been developed to maintain antegrade pelvic perfusion in patients undergoing endovascular repair. Maintaining antegrade perfusion may reduce a spectrum of risks, including buttock claudication, colorectal ischemia, and spinal cord ischemia when patients undergo subsequent thoracic aortic procedures, as well as erectile dysfunction (ED). This project specifically focuses on erectile function, and analyzes baseline associations and relationships of hypogastric artery exclusion on changes in erectile function following aneurysm repair. Male patients in the Veterans Affairs Open Versus Endovascular Repair (CSP#498; OVER) Trial had erectile function assessed preoperatively and postoperatively by administration of the International Index of Erectile Function-5 questionnaire. Bayesian mixed-effects regression models were created with the outcome variable (erectile function) treated as a latent variable. Primary effects of differences in erectile function between groups with and without preservation of bilateral antegrade hypogastric flow were compared. 876 men (442 randomized to endovascular repair) were enrolled in the trial and included in the analysis comparing treatment assignment. There is significant ED in elderly men with aortic aneurysm at baseline. Over 5years of follow-up, there is modest decrease in erectile function and the endovascular group has improved function compared to open repair (0.082; 95% credible interval (CI) 0.008 and 0.155). A fifth of patients did not have bilateral preservation of antegrade hypogastric artery perfusion, with no difference in erectile function by univariate analysis. A more detailed regression analysis was applied--and after adjustment for baseline score, age, beta blocker use, diabetes, activity level, ejection fraction, preoperative ankle-brachial indices and time--preservation of both antegrade hypogastric arteries' perfusion showed transient improvement in survey scores compared to occlusion of at least 1 hypogastric artery at 6months and 12months after treatment, although this was not sustained at 60months (score change: 0.046; 95% CI: -0.123, 0.215). Retesting this model in the cohort with complete data as a sensitivity analysis did not meaningfully change the conclusions. In this large prospective aneurysm treatment trial with systematic measurement of erectile function with a validated instrument, endovascular repair is associated with improved erectile function. Preservation of antegrade hypogastric flow with any repair is associated with early improved erectile function; however, it is not a sustained benefit. There is limited benefit of maintaining bilateral hypogastric artery perfusion for this specific indication in unselected men undergoing AAA repair.

Individual Patient Data Meta-Analysis of 10-Year Follow-Up after Endovascular and Open Repair for Ruptured Abdominal AorticAneurysms

Endovascular aortic repair (EVAR) has conferred an early survival advantage compared to an open surgical repair (OSR) in patients with ruptured abdominal aortic aneurysms (rAAA). However, the long-term survival benefit after EVAR was not displayed among randomized controlled trials (RCTs), whereas many non-RCTs have provided conflicting results. We conducted a time-to-event individual patient data (IPD) meta-analysis on long-term rAAA data. All studies comparing mortality after EVAR versus OSR for rAAA were included. We used restricted mean survival times (RMSTs) as a measure of life expectancy for EVAR and OSR. A total of 21 studies, including 12,187 patients (4952 EVAR and 7235 OSR) were finally deemed eligible. A secondary IPD analysis included 725 (372 EVAR and 353 OSR) patients only from the 3 RCTs (Immediate Management of the Patient With Rupture : Open Versus Endovascular Repair, Endovasculaire ou Chirurgie dans les Anévrysmes aorto-iliaques Rompus and Amsterdam Acute Aneurysm Trial trials). Among all studies, the median survival was 4.20 (95% confidence interval [CI]: 3.70-4.58) years for EVAR and 1.91 (95% CI: 1.57-2.39) years for OSR. Although EVAR presented with increased hazard risk from 4 to 7years, which peaked at 6years after the operation, the RMST difference was 0.54 (95% CI: 0.35-0.73; P<0.001) years gained with EVAR at the end of the 10-year follow-up. IPD meta-analysis of RCTs did not demonstrate significant differences. At 10-years follow-up, EVAR was associated with a 6.5month increase in life expectancy when compared to OSR after analyzing all eligible studies. Evidence from our study suggests that a strict follow-up program would be desirable, especially for patients with long-life expectancy.

Effect of preservation of antegrade hypogastric flow on development of claudication following aortoiliac aneurysm repair

ObjectiveThe objective of this study was to compare the rate of development of buttock claudication in patients undergoing aortoiliac aneurysm repair with and without exclusion of antegrade hypogastric arterial flow. In the absence of convincing data, questions remain regarding the best management of hypogastric arterial flow to prevent the theoretical risk of buttock claudication. MethodsThe Veterans’ Affairs Open Versus Endovascular Repair (OVER) Cooperative Study prospectively collected information on buttock claudication. Trial participants were specifically prompted both pre- and postoperatively to report the development of claudication symptoms at several anatomic levels. Of note, trial investigators were specifically trained to occlude the trunk hypogastric arterial, preserving the anterior and posterior divisions. Bayesian survival models were created to evaluate time to development of left, right, or bilateral buttock claudication according to the presence/absence of antegrade hypogastric perfusion. ResultsA total of 881 patients from the OVER trial with information regarding status of hypogastric flow were included in the analysis. Of these, 788 patients maintained bilateral antegrade hypogastric arterial perfusion, 63 had right hypogastric coverage/occlusion, and 27 had left hypogastric coverage/occlusion, whereas 3 patients had bilateral hypogastric coverage/occlusion. Just under 5% of all patients (n = 41) developed buttock claudication. After adjustment for smoking, chronic obstructive pulmonary disease, medications, study arm, preoperative activity level, body mass index, age, and diabetes, intervention-related changes to hypogastric perfusion had no effect on time to development of buttock claudication. A Maximum A Posteriori Kullback- Leibler misfit χ2 was 14.45 with 24 degrees of freedom, resulting in a goodness of fit P-value of P = .94, indicative of a good fit. ConclusionsOVER is the largest aneurysm treatment study to prospectively collect data related to the development of claudication as well as hypogastric preservation status. Despite this, we were unable to find evidence to support the assertion that preservation of antegrade hypogastric flow decreases the rate of development of buttock claudication symptoms. The low rate of development of buttock claudication overall and in the subgroups is striking.

Factors associated with preference of choice of aortic aneurysm repair in the PReference for Open Versus Endovascular repair of AAA (PROVE-AAA) study.

Patients can choose between open repair and endovascular repair (EVAR) of abdominal aortic aneurysm (AAA). However, the factors associated with patient preference for one repair type over another are not well-characterized. Here we assess the factors associated with preference of choice for open or endovascular AAA repair among veterans exposed to a decision aid to help with choosing surgical treatment. Across 12 Veterans Affairs hospitals, veterans received a decision aid covering domains including patient information sources and understanding preference. Veterans were then given a series of surveys at different timepoints examining their preferences for open versus endovascular AAA repair. Questions from the preference survey were used in analyses of patient preference. Results were analyzed using χ2 tests. A logistic regression analysis was performed to assess factors associated with preference for open repair or preference for EVAR. A total of 126 veterans received a decision aid informing them of their treatment choices, after which 121 completed all preference survey questions; five veterans completed only part of the instruments. Overall, veterans who preferred open repair were typically younger (70years vs 73years; P= .02), with similar rates of common comorbidities (coronary disease 16% vs 28%; P= .21), and similar aneurysms compared with those who preferred EVAR (6.0cm vs 5.7cm; P= .50). Veterans in both preference categories (28% of veterans preferring EVAR, 48% of veterans preferring open repair) reported taking their doctor's advice as the top box response for the single most important factor influencing their decision. When comparing the tradeoff between less invasive surgery and higher risk of long-term complications, more than one-half of veterans preferring EVAR reported invasiveness as more important compared with approximately 1 in 10 of those preferring open repair (53% vs 12%; P< .001). Shorter recovery was an important factor for the EVAR group (74%) and not important in the open repair group (76%) (P= .5). In multivariable analyses, valuing a short hospital stay (odds ratio, 12.4; 95% confidence interval, 1.13-135.70) and valuing a shorter recovery (odds ratio, 15.72; 95% confidence interval, 1.03-240.20) were associated with a greater odds of preference for EVAR, whereas finding these characteristics not important was associated with a greater odds of preference for open repair. When faced with the decision of open repair versus EVAR, veterans who valued a shorter hospital stay and a shorter recovery were more likely to prefer EVAR, whereas those more concerned about long-term complications preferred an open repair. Veterans typically value the advice of their surgeon over their own beliefs and preferences. These findings need to be considered by surgeons as they guide their patients to a shared decision.

Surgical Decision-Making and Outcomes in Open Versus Endovascular Repair for Various Vascular Diseases.

Today's vascular surgeon must navigate their practice through a field of ever-advancing technology while maintaining knowledge of open techniques that remain equally important in the care of their patients. In this article, the authors provide insight into the perioperative decision-making that goes into choosing a surgical plan for each patient based on their disease process, anatomy, nonmodifiable risk factors, and other comorbidities.

Chimney Versus Fenestrated Endovascular Versus Open Repair for Juxta/Pararenal Abdominal Aortic Aneurysms: Systematic Review and Network Meta-analysis of the Short-term Results.

The aim of this systematic review and network meta-analysis was to compare the short-term results of fenestrated endovascular repair (FEVAR), chimney endovascular repair (ChEVAR), and open surgery (OS) for patients with juxta/pararenal abdominal aortic aneurysms (JAAA/PAAA). MEDLINE, SCOPUS, and Web of Science were searched from inception to 1 July 2022. Any comparative studies investigating the results of two or three treatment strategies (ChEVAR, FEVAR, or OS) on clinical outcomes for patients with JAAA/PAAA were included. Analysed outcomes were 30-day mortality, acute kidney injury (AKI), major adverse cardiovascular events (MACE), and bowel ischaemia (BI). A total of 22 studies with 8853 patients were included in the analysis. FEVAR (OR = 0.58, 95%CrI 0.36-0.82) and ChEVAR (OR = 0.56, 95%CrI 0.28-1.02) were associated with lower 30-day mortality than OS. FEVAR (OR = 0.54, 95%CrI 0.33-0.85) was associated with lower risk of AKI than OS. FEVAR (OR = 0.43, 95%CrI 0.20-0.89) and ChEVAR (OR = 0.34, 95%CrI 0.10-0.93) compared to OS were associated with lower rates of BI. FEVAR (OR = 0.67, 95%CrI 0.49-0.90) and ChEVAR (OR = 0.61, 95%CrI 0.35-1.02) were associated with lower 30-day MACE risk than OS. FEVAR was associated with a higher rate of SCI compared to OS (OR = 4.90, 95%CrI 1.55-19.17). We found a clear benefit for FEVAR and ChEVAR versus OS in terms of reduced 30-day mortality, BI, and MACE, as well as AKI for FEVAR. This suggests that higher-risk patients might benefit from endovascular treatment of JAAA/PAAA; however, should be applied in clinical practice with caution, since long-term outcomes were outside of the scope of this review.

Treatment Modalities In Failed Aortic Endograft: Comparing Open Versus Endovascular Repair Outcomes

Treatment Modalities In Failed Aortic Endograft: Comparing Open Versus Endovascular Repair Outcomes

The Impact of Work Status and Age in Choosing Type of Abdominal Aortic Aneurysm Repair.

The PReferences for Open Versus Endovascular Repair of Abdominal Aortic Aneurysm (PROVE-AAA) trial aimed to determine the efficacy of a validated decision aid to enable better alignment between patient preference and their ultimate repair. We sought to determine the key factors influencing the decision-making of veterans for endovascular repair of abdominal aortic aneurysm (EVAR) or open surgical repair (OSR). A total of 235 veterans in the PROVE-AAA trial were asked their information sources regarding repairs, employment status, and preferred intervention. Answers were coded and analyzed using conventional content analysis to generate nonoverlapping themes, then stratified by employment status. Forty-two patients (17.8% of enrollees) provided their source of information for OSR prior to using a decision aid. 81% of retired veterans were greater than 70y old, while 58% of nonretired veterans were greater than 70 (P=0.003). The most common information source was from a vascular surgeon/professional or unspecified MD/other health professionals (51.4%), while sources from outside this group made up the remaining 48.5%. The most preferred procedure was EVAR. However, nonretired individuals were more likely to prefer OSR. These data on information source and preferred procedure were similar in patients who provided their source for EVAR. Veterans in the PROVE-AAA study were more likely to be retired and more likely to rely on information from an unspecified MD/other health professionals for EVAR. Although both retired and nonretired veterans preferred EVAR the most, nonretired veterans were more likely to prefer OSR despite being younger.

Deferred Abdominal Aortic Aneurysm Repair in Patients Who Meet Threshold Criteria for Repair

The Preferences for Open Versus Endovascular Repair of Abdominal Aortic Aneurysm (PROVE-AAA) is a randomized trial of a novel decision aid to assist veterans decide between AAA repair options. Over the trial period, a proportion of patients had repair of their aneurysm deferred. We examined the reasons for deferral of AAA repair and associated outcomes and patient characteristics.

Short-Term Concerns Primarily Determine Patient Preference for Abdominal Aortic Aneurysm Repair

Abdominal aortic aneurysm (AAA) repair may be performed through open or endovascular approaches, but the factors influencing a patient's repair-type preference are not well characterized. Here we performed a qualitative analysis to better understand factors influencing patient preference within the Preference for Open Versus Endovascular Repair of AAA Trial. Open-ended responses regarding primary (n=21) and secondary (n = 47) factors influencing patient preference underwent qualitative analysis using the constant comparative method with iterative reviews. Codes were used to generate themes and themes grouped into categories, with each step conducted via consensus agreement between three researchers. Relative prevalence of themes were compared to ascertain trends in patient preference. Patient responses regarding both primary and secondary factors fell into four categories: Short-term concerns, long-term concerns, advice & experience, and other. Patients most frequently described short-term concerns (23) as their primary influence, with themes including post-op complications, hospitalization & recovery, and intraoperative concerns. Long-term concerns were more prevalent (20) as secondary factors, which included themes such as survival, and chronic management. The average age of patients voicing only long-term concerns as a primary factor was 11 years younger than those listing only short-term concerns. Short-term concerns relating to the procedure and recovery are more often the primary factor influencing patient preference, while long term concerns play a more secondary role. Long-term concerns are more often a primary factor in younger patients. Vascular surgeons should consider this information in shared decision making to reach an optimal outcome.

Outcomes of Open Versus Endovascular Repair of Descending Thoracic and Thoracoabdominal Aortic Aneurysms

BackgroundOpen repair is the standard of care for patients with descending thoracic and thoracoabdominal aortic aneurysms. Although effective, surgery carries a high risk of morbidity and mortality. Endovascular stent grafts were introduced to treat these aneurysms in patients considered too high risk for open repair. Early results are promising, but later results are incompletely known. Therefore, we sought to compare short- and intermediate-term outcomes of open vs endovascular repair for these aneurysms. MethodsFrom 2000 to 2010, 1053 patients underwent open (n = 457) or endovascular (n = 596) repair of descending thoracic and thoracoabdominal aortic aneurysms at Cleveland Clinic. To balance patient characteristics between these groups, propensity score matching was performed, yielding 278 well-matched pairs (61% of possible pairs). End points included short- and long-term outcomes. ResultsIn matched patients, compared with endovascular stenting, open repair achieved similar in-hospital death (n = 23 [8.3%] vs n = 21 [7.6%], P = .80) and occurrence of paralysis and stroke (n = 10 [3.6%] vs n = 6 [2.2%], P = .30), despite a longer postoperative stay (median 11 vs 6 days), more dialysis-dependent acute renal failure (n = 24 [8.6%] vs n = 9 [3.3%], P = .008), and prolonged ventilation (n = 106 [46%] vs n = 17 [6.3%], P < .0001). Open repair resulted in better 10-year survival than endovascular repair (52% vs 33%, P < .0001), and aortic reintervention was less frequent (4% vs 21%, P < .0001). Despite a decrease in the first postoperative year, average aneurysm size did not recover to normal range after endovascular stenting. ConclusionsOpen repair of descending thoracic and thoracoabdominal aneurysms can achieve acceptable short-term outcomes with better intermediate-term outcomes than endovascular repair.

Society for Vascular Surgery implementation of clinical practice guidelines for patients with an abdominal aortic aneurysm: Endoleak management

Society for Vascular Surgery implementation of clinical practice guidelines for patients with an abdominal aortic aneurysm: Endoleak management

Decision Making Based on Clinicoanatomic Criteria to Select Open Versus Endovascular Repair for In nominate Artery Pseudoaneurysms Management

Background: The quality of present data on the effectiveness of endovascular repair (EVR) or open surgery (OS) to treat in nominate artery pseudoaneurysms (IAPs) is poor. The use of EV might simplify the procedure and provide a meaningful alternative for this condition, but it remains to be proved. We analyzed all IAP cases handled by OS or EVR from the literature to affect the decision-making for OS or EVR, basing the choice of intervention on clinicoanatomical data analysis. Methods and results: All relevant literature reports of EVR and OS management of IAP were analyzed comparatively. Evidence-based data were extracted from the literature using Medline and Embase database resources. We totally recorded 73 cases, 50 from OS repair and 23 received EVR. Most patients who displayed hard signs or stable vital signs have been significantly managed by OS (94% vs. 57%) or EVR (43%vs. 8%) respectively. There was a significant predominance of iatrogenic injuries in the EVR group compared with those handled by OS (39%vs. 26%) except for patients who underwent endovascular stenting. OS was performed in the large majority of patients with severe blunt traumas (50%vs. 22%)(p=0.0328). Many patients classified as having cardiothoracic comorbidities benefited from EVR therapy (52%vs. 20%). Some cases in which arterial wounds were limited to the mid segment of the IA underwent EVR with significant proportion compared to the OS group (26%vs. 24%) (p=0.004). Patients in the EVR group had more operative failure and complications rates (39%) rather than those in the OS group (20%) (p< 0.05). Of the 23 patients managed by EVR, two had premature mortality (8.7%); of the remaining cases that received OS, the early mortality rate represented 6%. The significant causes for OS-related morbimortality were multiple organ failures, acute right heart insufficiency, pneumonia, deep vein thrombosis and hemorrhagic shock. Overall events for EVR-related death included stroke complications and massive hemorrhage from endoleak. The mid-term follow-up rate was significantly higher for the EVR group (57%) compared to the OS group (30%). Conclusion: Compared with OS repair, EVR might represent an attractive alternative strategy for managing IAPs. The most primary option for OS included unstable patients, suffered from endovascular stenting, free of comorbidities and when the arterial wound is located at the distal portion of the IA.

Mortality for Endovascular Versus Open Repair for Ruptured Complex Abdominal Aortic Aneurysms: A Propensity-Weighted Analysis

Mortality for Endovascular Versus Open Repair for Ruptured Complex Abdominal Aortic Aneurysms: A Propensity-Weighted Analysis

Patient information sources when facing repair of abdominal aortic aneurysm

ObjectiveShared medical decision making is most important when there are competing options for repair such as in treatment of abdominal aortic aneurysm (AAA). We sought to understand the sources of patients' pre-existing knowledge about AAA to better inform treating physicians about patients' needs for preoperative counseling. MethodsWe performed a multicenter survey of patients facing AAA repair at 20 Veterans Affairs hospitals across the United States as part of the Preferences for Open Versus Endovascular Repair of AAA study. A validated survey instrument was administered to examine the sources of information available and commonly used by patients to learn about their repair options. The survey was administered by study personnel before the patient had any interaction with the vascular surgeon because survey data were collected before the vascular clinic visit. ResultsPreliminary analysis of data from 99 patients showed that our cohort was primarily male (99%) and elderly (mean age 73 years). Patients commonly had a history of hypertension (86%), prior myocardial infarction (32%), diabetes (32%), and were overweight (58%). Patients arrived at their surgeon's office appointment with limited information. A majority of patients (52%) reported that they had not talked to their primary care physician at all about their options for AAA repair, and one-half (50%) reported that their view of the different surgical options had not been influenced by anyone. Slightly less than one-half of patients reported that they did not receive any information about open surgical aneurysm repair and endovascular aortic aneurysm repair (41% and 37%, respectively). Few patients indicated using the internet as their main source of information about open surgical aneurysm repair and endovascular aortic aneurysm repair (10% and 11%, respectively). ConclusionsPatients are commonly referred for AAA repair having little to no information regarding AAA pathology or repair options. Fewer than one in five patients searched the internet or had accessed other sources of information on their own. Most vascular surgeons should assume that patients will present to their first vascular surgery appointment with minimal understanding of the treatment options available to them.

Acute Aortic Occlusion

Acute Aortic Occlusion

Type of Anesthesia for Endovascular Abdominal Aortic Aneurysm Repair

Endovascular aneurysm repair (EVAR) is used increasingly in the management of patients with abdominal aortic aneurysms (AAAs), including in the emergency setting for ruptured AAA. The lower mortality among patients undergoing emergency EVAR under local anesthesia (LA) observed in the Immediate Management of Patients with Rupture: Open Versus Endovascular Repair trial has sparked renewed interest in the anesthesia choice for EVAR. This systematic review evaluates the effect of mode of anesthesia on outcomes after EVAR. The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. The primary outcome was in-hospital/30-day mortality, and both emergency and elective EVAR were included. The relative risk of death was estimated for each individual study without adjustment for potential confounding factors. Hospitals. A total of 39,744 patients from 22 nonrandomized studies were included in the analysis. None. Sixteen studies in 23,202 patients compared LA to general anesthesia (GA) and reported in-hospital/30-day mortality. The unadjusted risk of death after emergency EVAR with LA was lower than with GA. Trends in elective surgery were less clear. There is some evidence across both emergency and elective settings to suggest that mode of anesthesia may be associated with improved outcomes. In particular, LA appears to have a positive effect on outcome after emergency EVAR. Because of the lack of randomized trial data, a significant risk of confounding remains. The optimal mode of anesthesia for EVAR should be investigated further and the reasons why particular anesthesia techniques are chosen for particular patients identified.

Invited commentary

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