EVAR Improves Aneurysm-Related Survival Over Surgery

January 24, 2013

MIAMI — Treating ruptured abdominal aortic aneurysms (AAAs) with minimally invasive endovascular repair saves more lives than surgical repair, according to a new Irish analysis. At 30 days, aneurysm-related survival was 70% for patients treated with endovascular aortic repair (EVAR) compared with 33% for patients who underwent open surgical repair.

"Until 2005, almost 85% of patients with ruptured abdominal aortic aneurysms were treated with open surgical repair, and only a handful received endovascular repair," lead investigator Dr Sherif Sultan (University College Hospital, Galway, Ireland) told heartwire . "From 2005 onward, we started to do the endovascular intervention. At the same time, we had a very active screening program for AAA and we had a very low threshold for intervention."

Presenting the results at the 2013 International Symposium on Endovascular Therapy (ISET), Sultan reported data on 568 AAAs operated on at University College Hospital in Galway, a tertiary referral center that takes patients from Donegal in the north of Ireland to patients from the south in Cork. Patients were referred to the hospital if they had a leaking or ruptured AAA, which was defined as blood outside the aortic artery. Of the 568 AAAs, 106 were confirmed ruptured AAAs, and of these, 75 patients were treated with surgery and 31 treated with EVAR.

As noted, there was a statistically significant improvement in aneurysm-related survival among the patients treated with EVAR. There was no significant difference in the rate of all-cause mortality. Aneurysm-related mortality was 12.5% in the first week after treatment, 25% at one month, 37.5% at six months, 50% at one year, and 90% at five years. To heartwire , Sultan stressed that EVAR is simply a palliative treatment option for patients with ruptured AAAs, as there is a high rate of mortality by five years.

"Regardless of the intervention, whether you have done an endovascular repair or an open repair, it's still palliative," said Sultan. "Almost 85% of these patients are dead within five years, even if they are 55 years of age. They don't survive. If we know that what we do is palliative, then we don't have patients in the intensive care unit, ending up on renal dialysis, and developing compartmental syndrome and bowel ischemia because we have opened them."

While patients have similar rates of death at five years with both EVAR and open repair, mainly from cardiovascular complications, EVAR is associated with a shorter hospital length of stay, fewer interventions and complications, less pneumonia, and fewer blood transfusions. "Basically, they do a lot better in the short amount of time that they are going to live," said Sultan. "They have a better quality of life."

Sultan said his team now treats AAAs that have reached 4.6 cm in diameter in women and 5.0 cm in diameter for men, a more aggressive approach compared with the traditional 5.5-cm diameter that is often used before intervening either surgically or with EVAR. This aggressive treatment threshold has allowed the hospital to decrease the rupture rate to less than three cases per year compared with 19 cases per year in years past.

"So it's not necessarily the endovascular repair of ruptured AAA that improves survival--it's a lot of things," he told heartwire . "First of all, there is a decrease in the number of AAAs referred to us for leaking AAA because of our aggressive screening program. We discovered that waiting for 5.5 cm is the threshold for disaster."