Open Repair of Ruptured Abdominal Aortic Aneurysm: The Suitability of Endovascular Aneurysm Repair Does Not Influence Operative Mortality

Abstract

Purpose:We analyze the outcomes of open repair (OR) in patients with ruptured abdominal aortic aneurysm (RAAA) according to the anatomic suitability for endovascular aneurysm repair (EVAR).Materials and Methods:We reviewed retrospectively all consecutive RAAA patients who underwent OR from January 2005 to March 2014. All suspected patients underwent preoperative computed tomography (CT). Outcomes were major morbidities and mortality. Multivariate analysis was performed by using logistic regression adjusted by controlled variables; gender, Hardman index, maximal aneurysmal diameter, rupture type, perioperative transfusion requirement, and perioperative urinary output.Results:Among 54 consecutive patients with RAAA who underwent OR, 45 patients were included after exclusion of 9 patients (7, suprarenal; 1, infected; 1, inflammatory). Preoperative CT showed 27% (12/45) EVAR-suitable patients. Hostile neck anatomy was found in 88% (29/33) among unsuitable anatomy (UA) (n=33). The maximal aneurysmal diameter was statistically larger (83.1±21.0 mm vs. 68.8±12.3 mm, P=0.032) in the UA group. The 30-day mortality was 28.9% (13/45; 33% vs. 17% in UA group vs. suitable anatomy [SA] group, P=0.460; adjusted P=0.445). UA group had more patients with cardiac morbidity (55% vs. 25%, P=0.079; adjusted P=0.032; odds ratio, 12.914; 95% confidence interval, 1.238–134.675). There was no statistical difference in survival rate between SA and UA groups (74.1%, 74.1%, and 74.1% vs. 60.6%, 55.6%, and 32.4% at 1-, 3- and 5-year, respectively; P=0.145).Conclusion:In this study, relatively unfavorable outcomes were found in the EVAR-unsuitable group after OR in RAAA patients. However, unsuitable anatomy did not influence patient survival after OR by multivariate analysis.

Systematic Review and Meta-Analysis of Outcomes of Open and Endovascular Repair of Ruptured Abdominal Aortic Aneurysm in Patients with Hostile vs. Friendly Aortic Anatomy

“…29,30 Specific information regarding the proportion of patients who were not suitable for EVAR because of proximal aortic neck or iliac anatomical constraints was provided in four studies. 16,20,21,25 Broos et al included only patients with hostile aortic neck anatomy. 21 In the study by van Beek et al, of the patients with CT available for detailed evaluation of aortic anatomy, 118 patients had non-favourable aortic neck and the remaining 28 patients had iliac anatomical restrictions.…”

“…16 Finally, Yoon et al reported hostile aortic neck anatomy in 87.9% and iliac artery anatomical constraints in 27.3%. 25 Observational data have demonstrated a peri-operative survival advantage for EVAR over open surgical repair for ruptured AAA. 2 Aortic morphology is considered an important confounding factor.…”