Endovascular repair of ruptured abdominal aortic aneurysms: A systematic review and meta-analysis

Mastracci, Tara M.; Garrido‐Olivares, Luis; Cinà, Claudio S.; Clase, Catherine M.

doi:10.1016/j.jvs.2007.07.052

Cited by 125 publications

(101 citation statements)

References 55 publications

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“…The first of the later randomised trials (AJAX) 19 The first results of 30-day mortality came from the Dutch trial (AJAX) in August 2013, 14,19 after recruitment to the IMPROVE trial had closed on 21 July 2013. AJAX reported a low 30-day mortality for both randomised groups (21% for the EVAR group and 25% for the open repair group; p = 0.66); however, this was a secondary outcome measure.…”

Section: Design Of the Recent Randomised Trialsmentioning

confidence: 99%

“…When this trial was first discussed, observational studies (synthesised in systematic reviews [11][12][13][14] were reporting much lower 30-day mortality for endovascular repair of ruptured AAAs and some such studies 11 have suggested that this should become the new gold standard treatment of ruptured aneurysms without the need for a randomised trial. In addition, the in-hospital and 1-year costs of treating ruptured aneurysms by endovascular repair may be up to 40% lower than for treatment by open repair.…”

Section: Chapter 1 Introductionmentioning

confidence: 99%

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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: Design Of the Recent Randomised Trialsmentioning

confidence: 99%

Section: Chapter 1 Introductionmentioning

confidence: 99%

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

View full text Add to dashboard Cite

show abstract

“…A systematic review and meta-analysis in 2008 reported a 21% mortality rate with EVAR for RAAAs. 4) Furthermore satisfactory clinical results of 'EVAR-first protocol' has been increasingly reported. 5,6) Speicher et al reported that EVAR should be strongly considered for all RAAA patients with acceptable anatomy.…”

Section: Resultsmentioning

confidence: 99%

Life-Saving Embolization in a Patient with Recurrent Shock Due to a Type II Endoleak after Endovascular Aortic Repair for a Ruptured Abdominal Aortic Aneurysm

Ogawa

Nishimaki

Chiba

et al. 2015

Annals of Vascular Diseases

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“…Following aortic rupture, endovascular surgery has shown promise in reducing mortality. Mortality rates following EVAR for rAAA are less than 20% in several non-randomised studies [1,21,[34][35][36][37] and 17-30.2% in other large metaanalyses [2,[38][39][40][41]. However, randomised controlled trial (RCT) data are currently lacking.…”

Section: Suitability For Evarmentioning

confidence: 99%

Anaesthesia for vascular emergencies

Ellard¹,

Djaiani

2012

Anaesthesia

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SummaryPatients presenting with vascular emergencies including acute aortic syndrome, ruptured thoracic or abdominal aortic aneurysms, thoracic aortic trauma and acute lower limb ischaemia have a high risk of peri-operative morbidity and mortality. Although anatomical suitability is not universal, endovascular surgery may improve mortality and the results of ongoing randomised controlled trials are awaited. Permissive hypotension pre-operatively should be the standard of care with the systolic blood pressure kept to 50-100 mmHg as long as consciousness is maintained. The benefit of local anaesthesia over general anaesthesia is not definitive and this decision should be tailored for a given patient and circumstance. Cerebrospinal fluid drainage for prevention of paraplegia is often impractical in the emergency setting and is not backed by strong evidence; however, it should be considered postoperatively if symptoms develop. We discuss the pertinent anaesthetic issues when a patient presents with a vascular emergency and the impact that endovascular repair has on anaesthetic management. In-hospital mortality after open repair of ruptured abdominal aortic aneurysm (rAAA) approaches 40-50% with total mortality, including pre-hospital deaths, closer to 80% [1][2][3]. Traumatic thoracic aortic injury is often immediately fatal with a 30-40% mortality in those who arrive alive to hospital and an overall mortality of 90% [4]. Thirty-day mortality rates are > 50% following ruptured thoracic aneurysm [5], 13% for acute type B dissection [6] and > 25% following embolectomy for acute limb ischaemia [7,8].We define a 'vascular emergency', for the purpose of this review, as an acute condition requiring intervention within hours, involving the descending aorta and its main lower limb branches. Specific pathologies meeting these criteria include acute aortic syndrome, ruptured thoracic and abdominal aneurysms, traumatic injuries of the thoracic aorta and acute lower limb ischaemia. Pathology involving the ascending aorta or aortic arch that is generally managed by cardiac surgeons is excluded.This review aims to discuss the optimal anaesthetic management to minimise morbidity and mortality and the impact of a move towards endovascular repair. An English language electronic search using Medline and Embase databases identified relevant scientific literature from the last 10 years and was supplemented with a manual search of reference lists from reviewed articles. Overview of vascular emergenciesAcute aortic syndrome Acute aortic syndrome consists of three interrelated conditions: penetrating atherosclerotic ulcer; intramural haematoma; and aortic dissection. Penetrating athero-

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Endovascular repair of ruptured abdominal aortic aneurysms: A systematic review and meta-analysis

Abstract: Mortality in people who underwent REVAR is lower than that in historical reports of unselected people undergoing open repair. Further investigation is needed to determine whether the difference in mortality is attributable to patient selection alone or to this new approach to treatment.

Cited by 125 publications

References 55 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

Life-Saving Embolization in a Patient with Recurrent Shock Due to a Type II Endoleak after Endovascular Aortic Repair for a Ruptured Abdominal Aortic Aneurysm

Anaesthesia for vascular emergencies

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