Endovascular or open repair of ruptured abdominal aortic aneurysms

Abstract

Endovascular repair of abdominal aortic aneurysms (EVAR) is a fascinating technology because it is minimally invasive but allows the treatment of even complex anatomical conditions. This has led to the fact that 75 % of all abdominal aortic aneurysms (AAA) were treated by EVAR [1]. A number of studies compared the outcomes after elective EVAR and surgery in patients with non-ruptured AAA, as recently shown in the Medicare database [1] with 40,000 propensity-score matched cases. In summary, a signifi cantly reduced in-hospital morbidity and mortality in favour of EVAR during the fi rst 2 to 3 years after intervention was found, but a higher rate of re-operations and ruptured AAA occurred after EVAR [1]. Although a fi nal conclusion could defi nitely not be drawn yet in elective cases, it has been assumed that the benefi ts of EVAR must become even more obvious in patients with ruptured AAA. This subgroup of patients is usually in a critical clinical condition, suff ering from a high early mortality of about 60 -80 % [1,2]. Therefore, a less invasive procedure should result in more favourable outcomes. EVAR in ruptured abdominal aneurysmsA recent meta-analysis [2] screened for all randomised controlled trials comparing EVAR to open repair in ruptured AAA using the Cochrane central register. Most studies were retrospective case-nested control studies (n = 10) or prospective observational studies (n = 5). Three randomised trials including a total of 761 patients were identifi ed, with 388 patients randomised for EVAR and 373 patients with open surgical repair. While Hinchliff e et al. [3] focused only on 30-day outcomes, the AJAX [4] and IMPROVE [5] trials also aimed at longer outcomes, although no long-term data from IMPROVE have been published to date. In summary, there was no diff erence regarding in-hospital or 30-day mortality between EVAR and surgery (OR 0.91, 95 % CI 0.67 to 1.22), as well as for in-hospital stroke (OR 0.71, 95 % CI 0.12 to 4.31) and cardiac complications (OR 1.12, 95 % CI 0.38 to 3.30). Also, postoperative renal failure (OR 0.7, 95 % CI 0.09 to 5.24) and bowel ischemia (OR 0.39, 95 % 0.07 to 2.11) were similar. Acute re-operation rate was also not diff erent between the two approaches (OR 0.89, 95 % CI 0.39 to 2.01). The AJAX trial [4] was the only study which evaluated spinal cord ischaemia and found no diff erences (OR 3.16,). The IMPROVE trial [5] (performed in the United Kingdom) assessed costs at 30 days but did not fi nd a signifi cant diff erence (13,433 GBP after EVAR compared to 14,619 GBP after open repair). However, this strongly depends on the national reimbursement systems and could not be extrapolated to other countries. Finally, only the AJAX trial reported 6 month results, also showing no benefi t for either of the 2 treatments regarding mortality (OR 0.89, 95 % CI 0.40 to 1.98) and re-operation rates (OR 1.28, 95 % CI 0.53 to 3.06). Consequences for daily routineAlthough several of the previous retrospective studies have reported a benefi t regarding major outcomes after EVA...