Emergency Endovascular Aneurysm Repair for Ruptured Abdominal Aortic Aneurysm: The Way Forward?

Oliver T.A. Lyons; Stephen Black; Rachel E. Clough; Rachel E. Bell; Tom Carrell; Matthew Waltham; Tarun Sabharwal; John Reidy; Peter R. Taylor

Disclosures

Vascular. 2010;18(3) 

In This Article

Abstract and Introduction

Abstract

We present the early results of a policy of treating all anatomically suitable ruptured abdominal aortic aneurysms (rAAAs) by emergency endovascular aneurysm repair (eEVAR), regardless of hemodynamic instability. Data were retrospectively collected from prospectively maintained databases identifying patients with rAAA from 2006 to 2007. Forty-seven patients with true rAAA were identified (87% men; median age 76 years [range 63–97 years]), of whom 18 (38%) were treated with eEVAR, 19 (40%) received open aneurysm repair (OAR), and 10 (21%) were managed nonoperatively. Fifteen of 18 (83%) eEVAR patients received an aortouni-iliac device + femorofemoral crossover, 2 patients (11%) had bifurcated devices, and 1 patient (6%) had a new iliac limb. Thirty-day mortality was 11% (2 of 18) for eEVAR and 32% (6 of 19) for OAR (p = not significant). At the 6-month follow-up, mortality was 22% (4 of 18) for eEVAR and 37% (7 of 19) for OAR (p = not significant). A clinically significant early survival advantage is suggested for eEVAR in patients presenting with rAAA.

Introduction

The mortality from ruptured abdominal aortic aneurysm (rAAA) remains high. Two recent meta-analyses of the results of surgery for rAAA showed that the average international operative mortality is approximately 48% and has shown little improvement since the 1970s despite advances in perioperative management.[1,2]

In the elective setting, an early survival advantage has been demonstrated for endovascular aneurysm repair (EVAR) over open aneurysm repair (OAR).[3,4] The first cases of emergency endovascular aneurysm repair (eEVAR) for rAAA were published in the 1990s,[5,6] and eEVAR has been demonstrated to be a valid treatment option.[7–9] Despite the intuitive advantages (no need for laparotomy and aortic cross-clamping), a benefit has yet to be demonstrated by a randomized controlled trial in the emergency setting.[10–14] The relative failure of more widespread use of eEVAR for rAAA is largely a result of anatomic limitations and a lack of specialist skills and equipment.[15,16]

Despite these considerations, the theoretical benefits of eEVAR over OAR in the emergency setting maintain the drive to demonstrate the usefulness of this technique. We examined the results of treatment of rAAA in a single center where eEVAR has been considered the treatment of choice in all anatomically suitable patients since the establishment of a dedicated consultant-led 24-hour endovascular service in 2006.

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