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One-Year Outcomes after Ruptured Abdominal Aortic Aneurysms Repair: Is Endovascular Aortic Repair the Best Choice? A Single-Center Experience.
Ann Vasc Surg. 2018 Nov; 53:63-69.AV

Abstract

BACKGROUND

Treatment of ruptured abdominal aortic aneurysms (rAAAs) is still burdened by high morbidity and mortality. Although endovascular aortic repair (EVAR) offers encouraging results in elective setting, its role as first-line strategy to treat rAAA is still debated. Our aim was to compare early and late outcomes in patients undergoing open surgical repair (OSR) versus EVAR for rAAAs.

METHODS

A retrospective review of data extracted from medical records identified 105 consecutive patients with rAAA who were submitted to open or endovascular repairs from 2008 to 2016. The primary end point was to assess the rAAA-related mortality in the immediate postoperative period, within 1 month and 1 year after OSR, and EVAR; secondary endpoints included the following: length of stay, AAA-related postoperative complications such as acute limb ischemia, myocardial infarction, renal and respiratory failure, and rAAA-related re-interventions. Statistical analysis was performed using the Fisher exact test, χ2 test, and logistic regression calculations. Early and midterm survival rates were assessed with Cox model.

RESULTS

Of the 105 patients with rAAA, 70.48% underwent OSR including 41.89% which was hemodynamically (Hd) unstable and the remaining 29.52% was submitted to rEVAR. (all Hd stable). Compared with EVAR group, the OSR group had a higher rAAA-related mortality rate for both Hd stable and Hd unstable patients: 18.92% vs. 6.45% at 24 hr; (P = 0.185) 39.19% vs. 19.35% at 30 days (P = 0.082); 44.59% vs. 38.71% at 1 year (P = 0.734) If only Hd stable patients were considered, mortality following OSR and EVAR was as follows: 6.98% vs. 6.45% at 24 hr (P = 0.703); 27.91% vs. 19.35% at 30 days (P = 0.567); 32.56% vs. 38.71% at 1 year (P = 0.764). Mean length of stay for patients was 15 days after OSR and 10 days after rEVAR (P = 0.002). At 1-year follow-up, the overall rAAA-related complications incidence was higher in the rEVAR group than that in the OSR group (47.85% vs. 18.33%; P = 0.008); re-interventions were 18.33% in OSR group vs. 21.82% in EVAR group (P = 0.917). Cox model showed that instability and coronary artery disease were predictors of overall mortality of rAAAs.

CONCLUSIONS

EVAR does not independently reduce 1-year mortality in comparison with OSR in Hd stable patients. Urgent EVAR for rAAAs in unstable patients can be limited by logistical problems. It follows that patients selected for OSR have a more complex aortic anatomy and worse Hd status than those submitted to rEVAR. rEVAR burdened by a higher incidence of procedure-related complications than OSR. Reconfiguration of acute aortic services and establishment of standardized institutional protocols might be advisable for improvements in the management of ruptured AAA. A careful evaluation of whether the benefits of an endovascular strategy translate into long term benefit is needed before definitive conclusions can be drawn about the advantages of EVAR as first-line strategy for ruptured aneurysms.

Authors+Show Affiliations

Division of Vascular Surgery, Paride Stefanini Department, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy.Division of Vascular Surgery, Paride Stefanini Department, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy.Division of Vascular Surgery, Paride Stefanini Department, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy.Division of Vascular Surgery, Paride Stefanini Department, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy.Department of Cardiovascular, Respiratory, Nephrological, Anesthesiological, and Geriatric Sciences, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy. Electronic address: francesco_irace@hotmail.it.Division of Vascular Surgery, Paride Stefanini Department, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy.Division of Vascular Surgery, Paride Stefanini Department, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy.Division of Vascular Surgery, Paride Stefanini Department, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy.Division of Vascular Surgery, Paride Stefanini Department, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy.

Pub Type(s)

Comparative Study
Journal Article

Language

eng

PubMed ID

29885434

Citation

Martinelli, Ombretta, et al. "One-Year Outcomes After Ruptured Abdominal Aortic Aneurysms Repair: Is Endovascular Aortic Repair the Best Choice? a Single-Center Experience." Annals of Vascular Surgery, vol. 53, 2018, pp. 63-69.
Martinelli O, Fenelli C, Ben-Hamida JB, et al. One-Year Outcomes after Ruptured Abdominal Aortic Aneurysms Repair: Is Endovascular Aortic Repair the Best Choice? A Single-Center Experience. Ann Vasc Surg. 2018;53:63-69.
Martinelli, O., Fenelli, C., Ben-Hamida, J. B., Fresilli, M., Irace, F. G., Picone, V., Malaj, A., Gossetti, B., & Irace, L. (2018). One-Year Outcomes after Ruptured Abdominal Aortic Aneurysms Repair: Is Endovascular Aortic Repair the Best Choice? A Single-Center Experience. Annals of Vascular Surgery, 53, 63-69. https://doi.org/10.1016/j.avsg.2018.04.004
Martinelli O, et al. One-Year Outcomes After Ruptured Abdominal Aortic Aneurysms Repair: Is Endovascular Aortic Repair the Best Choice? a Single-Center Experience. Ann Vasc Surg. 2018;53:63-69. PubMed PMID: 29885434.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - One-Year Outcomes after Ruptured Abdominal Aortic Aneurysms Repair: Is Endovascular Aortic Repair the Best Choice? A Single-Center Experience. AU - Martinelli,Ombretta, AU - Fenelli,Cecilia, AU - Ben-Hamida,Jamila Ben, AU - Fresilli,Mauro, AU - Irace,Francesco Giosuè, AU - Picone,Veronica, AU - Malaj,Alban, AU - Gossetti,Bruno, AU - Irace,Luigi, Y1 - 2018/06/06/ PY - 2017/10/16/received PY - 2017/12/12/revised PY - 2018/04/09/accepted PY - 2018/6/10/pubmed PY - 2019/1/15/medline PY - 2018/6/10/entrez SP - 63 EP - 69 JF - Annals of vascular surgery JO - Ann Vasc Surg VL - 53 N2 - BACKGROUND: Treatment of ruptured abdominal aortic aneurysms (rAAAs) is still burdened by high morbidity and mortality. Although endovascular aortic repair (EVAR) offers encouraging results in elective setting, its role as first-line strategy to treat rAAA is still debated. Our aim was to compare early and late outcomes in patients undergoing open surgical repair (OSR) versus EVAR for rAAAs. METHODS: A retrospective review of data extracted from medical records identified 105 consecutive patients with rAAA who were submitted to open or endovascular repairs from 2008 to 2016. The primary end point was to assess the rAAA-related mortality in the immediate postoperative period, within 1 month and 1 year after OSR, and EVAR; secondary endpoints included the following: length of stay, AAA-related postoperative complications such as acute limb ischemia, myocardial infarction, renal and respiratory failure, and rAAA-related re-interventions. Statistical analysis was performed using the Fisher exact test, χ2 test, and logistic regression calculations. Early and midterm survival rates were assessed with Cox model. RESULTS: Of the 105 patients with rAAA, 70.48% underwent OSR including 41.89% which was hemodynamically (Hd) unstable and the remaining 29.52% was submitted to rEVAR. (all Hd stable). Compared with EVAR group, the OSR group had a higher rAAA-related mortality rate for both Hd stable and Hd unstable patients: 18.92% vs. 6.45% at 24 hr; (P = 0.185) 39.19% vs. 19.35% at 30 days (P = 0.082); 44.59% vs. 38.71% at 1 year (P = 0.734) If only Hd stable patients were considered, mortality following OSR and EVAR was as follows: 6.98% vs. 6.45% at 24 hr (P = 0.703); 27.91% vs. 19.35% at 30 days (P = 0.567); 32.56% vs. 38.71% at 1 year (P = 0.764). Mean length of stay for patients was 15 days after OSR and 10 days after rEVAR (P = 0.002). At 1-year follow-up, the overall rAAA-related complications incidence was higher in the rEVAR group than that in the OSR group (47.85% vs. 18.33%; P = 0.008); re-interventions were 18.33% in OSR group vs. 21.82% in EVAR group (P = 0.917). Cox model showed that instability and coronary artery disease were predictors of overall mortality of rAAAs. CONCLUSIONS: EVAR does not independently reduce 1-year mortality in comparison with OSR in Hd stable patients. Urgent EVAR for rAAAs in unstable patients can be limited by logistical problems. It follows that patients selected for OSR have a more complex aortic anatomy and worse Hd status than those submitted to rEVAR. rEVAR burdened by a higher incidence of procedure-related complications than OSR. Reconfiguration of acute aortic services and establishment of standardized institutional protocols might be advisable for improvements in the management of ruptured AAA. A careful evaluation of whether the benefits of an endovascular strategy translate into long term benefit is needed before definitive conclusions can be drawn about the advantages of EVAR as first-line strategy for ruptured aneurysms. SN - 1615-5947 UR - https://www.unboundmedicine.com/medline/citation/29885434/One_Year_Outcomes_after_Ruptured_Abdominal_Aortic_Aneurysms_Repair:_Is_Endovascular_Aortic_Repair_the_Best_Choice_A_Single_Center_Experience_ L2 - https://linkinghub.elsevier.com/retrieve/pii/S0890-5096(18)30418-7 DB - PRIME DP - Unbound Medicine ER -