Ruptured AAA: Suitability for Endovascular Repair is Associated with Lower Mortality Following Open Repair

Objectives

Perioperative mortality of open repair of ruptured abdominal aortic aneurysms (rAAA) remains unacceptably high: 30-day mortality ≈40 %. This study aimed to assess, quantify, and determine the consequences of anatomic suitability for endovascular repair of rAAA.

Design

A retrospective analysis of the prospectively maintained database identified patients with rAAA.

Methods

Preoperative CT scans were assessed for anatomic suitability for emergency EVAR and precluding factors recorded. Demographic information was collected and analysed for all patients.

Results

A total of 141 patients underwent open surgical repair of rAAA. Forty-six patients had preoperative CT scans suitable for reconstruction. Morphological measurements indicated that 41 % would have been anatomically suitable for EVAR. Suitability was associated with lower mortality rates than unsuitability: 0, 11, and 20 % (24 h, 30 days, and 1 year respectively) versus 11, 33, and 59 % (statistically significant at 1 year; p = 0.02). The groups were comparable excepting diabetes incidence, which was higher in those suitable for EVAR (p = 0.003).

Conclusions

A minority of patients with ruptured AAA are anatomically suitable for EVAR. Anatomical suitability appears to identify patients at low risk from open surgery. Whether this is due to technically less demanding open surgery is unknown. This may be resolved by the IMPROVE trial results, which are eagerly awaited.     

Endovascular Repair for Ruptured AAA: A Literature Review

The reduced physiological impact of endovascular aneurysm repair (EVAR) compared with conventional open repair has been demonstrated. If this technique could be used routinely in patients with ruptured abdominal aortic aneurysm (AAA) it may reduce the high peri-operative mortality.

This review of the literature identified the current experience with EVAR of ruptured AAA. Only a small number of case series with selected patients are reported. These patients were selected for their haemodynamic stability, and their suitable aneurysm morphology. The overall anatomic suitability rates for EVAR reported, suggest an applicability of 58% to 80% from an intent-to-treat experience.

The average post-operative mortality rate was 24%, ranging from 9 to 45% and may reflect increasing experience and patient selection.

Important lessons have been learned from these first experiences that help to define a clear position of EVAR as an additional therapeutic option for ruptured AAA.     

Anatomical Suitability For Endovascular AAA Repair May Affect Outcomes following Rupture

ObjectivesSingle centre series have suggested that endovascular aneurysm repair (EVAR) for ruptured abdominal aortic aneurysms (rAAA) may reduce mortality versus open surgery. This has not been substantiated in the only randomized controlled trial, leading to suggestion that anatomical suitability for rEVAR may independently improve prognosis of rAAA. Our aim was to assess the outcome of open rAAA repair in patients dependant on their suitability for rEVAR on pre-operative computed tomography (CT) assessment.MethodsA retrospective review of all ruptured aneurysms presenting to our unit since January 1998 was performed. Patients were grouped based on anatomical suitability for rEVAR by pre-operative CT.ResultsOf 118 patients presenting with rAAA, 48 underwent pre-operative CT. Of these 9 scans had been “culled” and were excluded. 16 patients were suitable for rEVAR and 23 unsuitable. The groups were well matched demographically with no difference in Glasgow Aneurysm Score between groups. There was a non-significant trend towards reduction in 30-day mortality for patients suitable for EVAR (suitable 6.9% versus unsuitable 30.4%; P = 0.066) with no difference in operative time, transfusion requirement, length of stay or in-hospital morbidity.ConclusionsAnatomical suitability for EVAR seems to beneficially affect outcome following open repair for ruptured AAA. Further study is required to confirm these findings.     

Endovascular Repair of Carotid Artery Aneurysms Following Carotid Endarterectomy

Aneurysm of the carotid artery following endarterectomy is a rare entity that historically has required reoperation. Endovascular deployment of a covered stent can theoretically exclude an aneurysm while minimizing the risks seen with reoperation. Herein, we review the scientific literature on this evolving technique and report an additional case involving successful treatment of an aneurysm that developed following remote endarterectomy.