Endovascular Suitability and Outcome After Open Surgery for Ruptured Abdominal Aortic Aneurysm

Abstract

Background: Endovascular repair of ruptured abdominal aortic aneurysm (rAAA) has rapidly gained popularity, but superior results may be biased by patient selection. The aim was to investigate whether suitability for endovascular repair predicted survival, irrespective of technique of repair. Methods: Two blinded investigators independently evaluated preoperative computed tomography angiograms of a consecutive cohort of patients with rAAA. Patients were categorized either ‘suitable’ or ‘unsuitable’ for endovascular repair, if assessments agreed. If assessments disagreed, they were classified ‘borderline suitable’. Correlations between endovascular suitability and clinical outcome were adjusted for suspected confounding factors and tested for robustness using sensitivity analyses. Results: A total of 248 patients with rAAA from January 2001 to December 2010 were included, of whom 237 (95·6 per cent) underwent open repair. Seventy patients (28·2 per cent) were classified as ‘suitable’ and 100 (40·3 per cent) as ‘unsuitable’ for endovascular repair; 63 (25·4 per cent) were considered ‘borderline suitable’. Fifteen (6·0 per cent) could not be assessed and were included in the sensitivity analyses. The postoperative 30‐day mortality rate was 15·3 per cent (38 deaths). Multiple logistic regression demonstrated that the odds of perioperative death increased 9·21 (95 per cent confidence interval 2·16 to 39·23) fold for ‘unsuitable’ rAAA (P = 0·003) and 6·80 (1·47 to 31·49) fold for ‘borderline’ rAAA (P = 0·014), compared with ‘suitable’ rAAA. This selection effect was robust across sensitivity analyses and sustained for at least 5 years of follow‐up. Conclusion: Endovascular suitability was an independent and strongly positive predictor of survival after open repair of rAAA. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Ruptured Aneurysm Trials: The Importance of Longer-term Outcomes and Meta-analysis for 1-year Mortality

“…It also is important to recognise that outside the pioneering vascular centres, open repair will be needed often for the 35e40% of patients who are not suitable for conventional EVAR and therefore have an intrinsically higher mortality risk. 15,16 In summary, after three recent randomised trials and 1 year of patient follow-up the evidence suggests that although endovascular repair does not offer a significant survival advantage, endovascular repair should be used more widely. Nevertheless open repair must remain available for those unsuitable for conventional EVAR.…”

Outcomes of EVAR with the endurant stent-graft system in patients with infrarenal ruptured abdominal aortic aneurysms: Is hostile anatomy a challenging factor?

“…EVAR for AAA is increasingly being used [13]. In previous studies, 40-58% of the rAAAs were found to be "unsuitable" for endovascular repair, and endovascular suitability was found to be an independent and strongly positive predictor of survival after open repair of rAAA [14][15]. The suitability for EVAR in those previous studies was defined by the following criteria: proximal neck length >10 mm; proximal neck diameter <32 mm; proximal neck angulation <90 • , widely accepted in the clinical setting; landing zone for a stent graft in at least one iliac artery (iliac diameter <20 mm); reversed taper morphology with a >3 mm larger neck diameter proximally versus distally; no significant proximal neck thrombus or calcification; and appropriate femoral artery vessel with a diameter >6 mm [14][15].…”

Valor pronóstico de la anatomía EVAR en el tratamiento quirúrgico del aneurisma de aorta abdominal roto

“…Recientemente, el subanálisis de 279 pacientes incluidos en el AJAX-trial ha mostrado que la mortalidad de los pacientes operados con cirugía abierta por AAAr era comparable entre los pacientes con una anatomía aortoilíaca favorable (38%) u hostil para EVAR (30%), si bien los criterios aplicados de selección y la distribución no balanceada de pacientes entre ambos grupos (71 favorables vs. 208 no favorables) pueden explicar los resultados. Aquí en nuestro país, la experiencia en el Hospital Juan Canalejo 12 y Hospital 12 de Octubre 13 parecen reforzar nuestra hipótesis de que la presencia de una anatomía aórtica hostil puede justificar peores resultados quirúrgi-cos. En este sentido, un reciente estudio retrospectivo de 233 pacientes analizados en el condado de Berna (Suiza) corroboró en el análisis multivariante que el riesgo de muerte a 30 días era más alto en aquellos pacientes con una anatomía no favorable para EVAR (odd ratio: 24%; CI 95%: 17-33) 14 .…”