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Management of ruptured abdominal aortic aneurysm in the endovascular era.
J Vasc Surg. 2010 Jan; 51(1):9-17; discussion 17-8.JV

Abstract

OBJECTIVES

Our institution treats about 30 patients per year with ruptured abdominal aortic aneurysms (rAAA). Between 2002 and 2007, our 30-day mortality averaged 58%. In July 2007, we implemented an algorithm to promote endovascular aneurysm repair (EVAR) when feasible. This report describes the outcome with this approach.

METHODS

Data on patients presenting with rAAA between July 1, 2002, and June 30, 2007, were reviewed and used for comparison to prospectively collected data. Data on patients presenting between July 1, 2007, and April 30, 2009, were collected on all patients after implementation of a structured protocol. The primary outcome measure was 30-day mortality. Data were analyzed using logistic regression. Kaplan-Meier survival curves and a log-rank test were performed to compare survival times for three groups (pre-protocol, post-protocol with open surgery, and post-protocol with EVAR).

RESULTS

During the study period, 187 patients with rAAA presented to our institution. Before implementation of the algorithm, 131 patients with rAAA presented and 128 were treated. The 30-day mortality rate was 57.8%. After implementation of the protocol, 56 patients with rAAA were managed. Twenty-seven patients (48%) underwent successful EVAR, and 24 patients (43%) underwent open repair. Five patients (9%) underwent comfort care only. In the post-protocol period, 5 patients in the EVAR group (18.5%) and 13 patients in the open group (54.2%) died during the follow-up period for an overall 30-day mortality rate of 35.3% (P = .008 vs 57.8% pre-protocol). After implementation of a structured protocol for managing rAAA, there was a relative risk reduction in 30-day mortality of 35% compared to the time before implementation of the protocol (95% confidence interval [CI], 14%-51%) corresponding to an absolute risk reduction of 22.5% (95% CI, 6.8%-38.2%) and an odds ratio of 0.40 (95% CI, 0.20-0.78; P = .007). After adjusting for key factors predicting mortality, the odds ratio is 0.25 (95% CI, 0.10-0.57; P = .001).

CONCLUSION

Use of an algorithm favoring endovascular repair resulted in a highly significant reduction in rAAA mortality in our urban hospital. Thirty-day mortality for open repair was no different between pre- and post-protocol eras. With modern techniques of resuscitation and surgical management, a majority of patients presenting with rAAA can survive.

Authors+Show Affiliations

Division of Vascular Surgery, University of Washington, Seattle, Wash 98104, USA. starnes@u.washington.eduNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Comparative Study
Journal Article

Language

eng

PubMed ID

19883986

Citation

Starnes, Benjamin W., et al. "Management of Ruptured Abdominal Aortic Aneurysm in the Endovascular Era." Journal of Vascular Surgery, vol. 51, no. 1, 2010, pp. 9-17; discussion 17-8.
Starnes BW, Quiroga E, Hutter C, et al. Management of ruptured abdominal aortic aneurysm in the endovascular era. J Vasc Surg. 2010;51(1):9-17; discussion 17-8.
Starnes, B. W., Quiroga, E., Hutter, C., Tran, N. T., Hatsukami, T., Meissner, M., Tang, G., & Kohler, T. (2010). Management of ruptured abdominal aortic aneurysm in the endovascular era. Journal of Vascular Surgery, 51(1), 9-17; discussion 17-8. https://doi.org/10.1016/j.jvs.2009.08.038
Starnes BW, et al. Management of Ruptured Abdominal Aortic Aneurysm in the Endovascular Era. J Vasc Surg. 2010;51(1):9-17; discussion 17-8. PubMed PMID: 19883986.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Management of ruptured abdominal aortic aneurysm in the endovascular era. AU - Starnes,Benjamin W, AU - Quiroga,Elina, AU - Hutter,Carolyn, AU - Tran,Nam T, AU - Hatsukami,Thomas, AU - Meissner,Mark, AU - Tang,Gale, AU - Kohler,Ted, Y1 - 2009/11/01/ PY - 2009/06/16/received PY - 2009/08/05/revised PY - 2009/08/06/accepted PY - 2009/11/4/entrez PY - 2009/11/4/pubmed PY - 2010/2/24/medline SP - 9-17; discussion 17-8 JF - Journal of vascular surgery JO - J Vasc Surg VL - 51 IS - 1 N2 - OBJECTIVES: Our institution treats about 30 patients per year with ruptured abdominal aortic aneurysms (rAAA). Between 2002 and 2007, our 30-day mortality averaged 58%. In July 2007, we implemented an algorithm to promote endovascular aneurysm repair (EVAR) when feasible. This report describes the outcome with this approach. METHODS: Data on patients presenting with rAAA between July 1, 2002, and June 30, 2007, were reviewed and used for comparison to prospectively collected data. Data on patients presenting between July 1, 2007, and April 30, 2009, were collected on all patients after implementation of a structured protocol. The primary outcome measure was 30-day mortality. Data were analyzed using logistic regression. Kaplan-Meier survival curves and a log-rank test were performed to compare survival times for three groups (pre-protocol, post-protocol with open surgery, and post-protocol with EVAR). RESULTS: During the study period, 187 patients with rAAA presented to our institution. Before implementation of the algorithm, 131 patients with rAAA presented and 128 were treated. The 30-day mortality rate was 57.8%. After implementation of the protocol, 56 patients with rAAA were managed. Twenty-seven patients (48%) underwent successful EVAR, and 24 patients (43%) underwent open repair. Five patients (9%) underwent comfort care only. In the post-protocol period, 5 patients in the EVAR group (18.5%) and 13 patients in the open group (54.2%) died during the follow-up period for an overall 30-day mortality rate of 35.3% (P = .008 vs 57.8% pre-protocol). After implementation of a structured protocol for managing rAAA, there was a relative risk reduction in 30-day mortality of 35% compared to the time before implementation of the protocol (95% confidence interval [CI], 14%-51%) corresponding to an absolute risk reduction of 22.5% (95% CI, 6.8%-38.2%) and an odds ratio of 0.40 (95% CI, 0.20-0.78; P = .007). After adjusting for key factors predicting mortality, the odds ratio is 0.25 (95% CI, 0.10-0.57; P = .001). CONCLUSION: Use of an algorithm favoring endovascular repair resulted in a highly significant reduction in rAAA mortality in our urban hospital. Thirty-day mortality for open repair was no different between pre- and post-protocol eras. With modern techniques of resuscitation and surgical management, a majority of patients presenting with rAAA can survive. SN - 1097-6809 UR - https://www.unboundmedicine.com/medline/citation/19883986/Management_of_ruptured_abdominal_aortic_aneurysm_in_the_endovascular_era_ L2 - https://linkinghub.elsevier.com/retrieve/pii/S0741-5214(09)01679-6 DB - PRIME DP - Unbound Medicine ER -