Re-interventions After Repair of Ruptured Abdominal Aortic Aneurysm: A Report From the IMPROVE Randomised Trial

Abstract

WHAT THIS PAPER ADDSThe mid-term re-intervention rate after ruptured abdominal aortic aneurysm repair by endovascular or open repair appears to be twice as high as after elective repair. This suggests the need for bespoke surveillance protocols after rupture. Limb ischaemia is a frequent early reason and distal aneurysms a frequent later reason for re-intervention to indicate where quality improvement programmes might be directed. Limb amputation is uncommon but higher after open repair than after endovascular aneurysm repair.Objective/Background: The aim was to describe the re-interventions after endovascular and open repair of rupture, and investigate whether these were associated with aortic morphology. Methods: In total, 502 patients from the IMPROVE randomised trial (ISRCTN48334791) with repair of rupture were followed-up for re-interventions for at least 3 years. Pre-operative aortic morphology was assessed in a core laboratory. Re-interventions were described by time (0e90 days, 3 monthse3 years) as arterial or laparotomy related, respectively, and ranked for severity by surgeons and patients separately. Rare re-interventions to 1 year, were summarised across three ruptured abdominal aortic aneurysm trials (IMPROVE, AJAX, and ECAR) and odds ratios (OR) describing differences were pooled via meta-analysis. Results: Re-interventions were most common in the first 90 days. Overall rates were 186 and 226 per 100 person years for the endovascular strategy and open repair groups, respectively (p ¼ .20) but between 3 months and 3 years (mid-term) the rates had slowed to 9.5 and 6.0 re-interventions per 100 person years, respectively (p ¼ .090) and about one third of these were for a life threatening condition. In this latter, mid-term period, 42 of 313 remaining patients (13%) required at least one re-intervention, most commonly for endoleak or other endograft complication after treatment by endovascular aneurysm repair (EVAR) (21 of 38 re-interventions), whereas distal aneurysms were the commonest reason (four of 23) for re-interventions after treatment by open repair. Arterial re-interventions within 3 years were associated with increasing common iliac artery diameter (OR 1.48, 95% confidence interval [CI] 0.13e0.93; p ¼ .004). Amputation, rare but ranked as the worst reintervention by patients, was less common in the first year after treatment with EVAR (OR 0.2, 95% CI 0.05e0.88) from meta-analysis of three trials. Conclusion: The rate of mid-term re-interventions after rupture is high, more than double that after elective EVAR and open repair, suggesting the need for bespoke surveillance protocols. Amputations are much less common in patients treated by EVAR than in those treated by open repair.

Temporal Trends and Management of Acute Aortic Occlusion: A 21 Year Experience

“…16 In the UK IMPROVE trial, which randomised patients with ruptured AAA between open repair and EVAR, occlusion of the reconstructions were more common after EVAR. 28 Another contributing factor to the observed increase in graft/stent/stent graft occlusions might be the overall increase in the frequency aortic interventions, leaving more patients with aortic reconstructions that can possibly occlude.…”