Challenging Anatomy Predicts Mortality and Complications After Endovascular Treatment of Ruptured Abdominal Aortic Aneurysm

Hassan, A. Bassim; Gonçalves, Frederico Bastos; Oliveira, Nélson; Verhagen, Hence J.M.; Wanhainen, Anders; Björck, Martin; Mani, Kevin

doi:10.1177/1526602816658494

Cited by 30 publications

(22 citation statements)

References 33 publications

(31 reference statements)

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“…However, we have shown, in an individual patient data meta-analysis, that the association for open repair was also observed for patients randomised in the AJAX 19 and ECAR 22 trials (in which all participants were morphologically eligible for EVAR). 51 There is support for such findings from Baderkhan et al, 73 who reported, based on 112 participants undergoing EVAR, that both the number of reinterventions and 3-year mortality were significantly higher for those repaired within the IFU than for those repaired outside the IFU. However, others may hold different opinions: van Beek et al 70 studied 279 consecutive participants undergoing open repair and concluded that participants with 'hostile' and 'friendly' aortic necks had similar 30-day mortality.…”

Section: Factors Other Than the Type Of Repair That Influence 30-day mentioning

confidence: 85%

Strategy of endovascular versus open repair for patients with clinical diagnosis of ruptured abdominal aortic aneurysm: the IMPROVE RCT

Ulug

Hinchliffe

Sweeting

et al. 2018

Health Technol Assess

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Background Ruptured abdominal aortic aneurysm (AAA) is a common vascular emergency. The mortality from emergency endovascular repair may be much lower than the 40–50% reported for open surgery. Objective To assess whether or not a strategy of endovascular repair compared with open repair reduces 30-day and mid-term mortality (including costs and cost-effectiveness) among patients with a suspected ruptured AAA. Design Randomised controlled trial, with computer-generated telephone randomisation of participants in a 1 : 1 ratio, using variable block size, stratified by centre and without blinding. Setting Vascular centres in the UK (n = 29) and Canada (n = 1) between 2009 and 2013. Participants A total of 613 eligible participants (480 men) with a ruptured aneurysm, clinically diagnosed at the trial centre. Interventions A total of 316 participants were randomised to the endovascular strategy group (immediate computerised tomography followed by endovascular repair if anatomically suitable or, if not suitable, open repair) and 297 were randomised to the open repair group (computerised tomography optional). Main outcome measures The primary outcome measure was 30-day mortality, with 30-day reinterventions, costs and disposal as early secondary outcome measures. Later outcome measures included 1- and 3-year mortality, reinterventions, quality of life (QoL) and cost-effectiveness. Results The 30-day mortality was 35.4% in the endovascular strategy group and 37.4% in the open repair group [odds ratio (OR) 0.92, 95% confidence interval (CI) 0.66 to 1.28; p = 0.62, and, after adjustment for age, sex and Hardman index, OR 0.94, 95% CI 0.67 to 1.33]. The endovascular strategy appeared to be more effective in women than in men (interaction test p = 0.02). More discharges in the endovascular strategy group (94%) than in the open repair group (77%) were directly to home (p < 0.001). Average 30-day costs were similar between groups, with the mean difference in costs being –£1186 (95% CI –£2997 to £625), favouring the endovascular strategy group. After 1 year, survival and reintervention rates were similar in the two groups, QoL (at both 3 and 12 months) was higher in the endovascular strategy group and the mean cost difference was –£2329 (95% CI –£5489 to £922). At 3 years, mortality was 48% and 56% in the endovascular strategy group and open repair group, respectively (OR 0.73, 95% CI 0.53 to 1.00; p = 0.053), with a stronger benefit for the endovascular strategy in the subgroup of 502 participants in whom repair was started for a proven rupture (OR 0.62, 95% CI 0.43 to 0.89; p = 0.009), whereas aneurysm-related reintervention rates were non-significantly higher in this group. At 3 years, considering all participants, there was a mean difference of 0.174 quality-adjusted life-years (QALYs) (95% CI 0.002 to 0.353 QALYs) and, among the endovascular strategy group, a cost difference of –£2605 (95% CI –£5966 to £702), leading to 88% of estimates in the cost-effectiveness plane being in the quadrant showing the endovascular strategy to be ‘dominant’. Limitations Because of the pragmatic design of this trial, 33 participants in the endovascular strategy group and 26 in the open repair group breached randomisation allocation. Conclusions The endovascular strategy was not associated with a significant reduction in either 30-day mortality or cost but was associated with faster participant recovery. By 3 years, the endovascular strategy showed a survival and QALY gain and was highly likely to be cost-effective. Future research could include improving resuscitation for older persons with circulatory collapse, the impact of local anaesthesia and emergency consent procedures. Trial registration Current Controlled Trials ISRCTN48334791 and NCT00746122. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 31. See the NIHR Journals Library website for further project information.

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Section: Factors Other Than the Type Of Repair That Influence 30-day mentioning

confidence: 85%

Strategy of endovascular versus open repair for patients with clinical diagnosis of ruptured abdominal aortic aneurysm: the IMPROVE RCT

Ulug

Hinchliffe

Sweeting

et al. 2018

Health Technol Assess

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“…The anatomy of rAAA is associated with its prognosis. 9) Notably, because the patient is first stabilized by IABO, the strategy described in this report can safely be converted from EVAR to open surgery when anatomical incompatibility is identified. Indeed, one patient in the present study who was admitted to our hospital with rAAA was successfully converted to open surgery after IABO, and he survived to discharge.…”

Section: Discussionmentioning

confidence: 95%

Ruptured Abdominal Aortic Aneurysm Treated by Double-Balloon Technique and Endovascular Strategy: Case Series

Nakayama

Toma

Kobayashi

et al. 2018

ATCS

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“…Stratification of post‐EVAR follow‐up based on the risk of graft failure would increase the efficacy of follow‐up programmes and reduce unnecessary patient exposure to examinations. Risk factors associated with higher post‐EVAR adverse events include intraoperative complications and adjunctive procedures, hostile anatomy or use of stent‐grafts outside instructions for use, and lack of sac shrinkage in the postoperative interval. The presence of an adequate sealing zone and no endoleak on the first postoperative CT angiogram (CTA) has been shown to predict a low risk of complications for up to 5 years after EVAR in a limited single‐centre cohort of patients treated with a specific type of stent‐graft.…”

Section: Introductionmentioning

confidence: 99%

Follow-up after endovascular aortic aneurysm repair can be stratified based on first postoperative imaging

Hassan

Haller

Wanhainen

et al. 2018

British Journal of Surgery

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Challenging Anatomy Predicts Mortality and Complications After Endovascular Treatment of Ruptured Abdominal Aortic Aneurysm

Abstract: Long-term mortality and complications after rEVAR are associated with aneurysm anatomy. The role of adjunct endovascular techniques and the outcome of open repair in cases with challenging anatomy warrant further study.

Cited by 30 publications

References 33 publications

Strategy of endovascular versus open repair for patients with clinical diagnosis of ruptured abdominal aortic aneurysm: the IMPROVE RCT

Strategy of endovascular versus open repair for patients with clinical diagnosis of ruptured abdominal aortic aneurysm: the IMPROVE RCT

Ruptured Abdominal Aortic Aneurysm Treated by Double-Balloon Technique and Endovascular Strategy: Case Series

Follow-up after endovascular aortic aneurysm repair can be stratified based on first postoperative imaging

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