Endovascular treatment of ruptured abdominal aortic aneurysms: a shift of the paradigm?

To compare endovascular aneurysm repair (EVAR) of ruptured abdominal aortic aneurysms (rAAA) to the results with open surgery.

Between May 2001 and January 2004, 50 patients were diagnosed with rAAA. Fifteen (30%) patients (14 men; median age 73 years, range 58-85) underwent EVAR, while 26 (52%) patients (23 men; median age 75 years, range 60-84) had open surgery. Nine (18%) patients (5 men; median age 86 years, range 77-91) were not operated upon. Circulatory shock was defined as systolic blood pressure<80 mmHg. Mortality was defined as death within 30 days after operation; in cases where hospital stay exceeded 30 days, in-hospital mortality was registered. Five risk factors (age>76 years, loss of consciousness, hemoglobin<90 g/L, creatinine>190 micromol/L, and electrocardiographic ischemia) were analyzed.

In the EVAR group, 93% (14/15) of the aneurysms were excluded from the bloodstream; there were 2 (13%) conversions: 1 intraoperatively for stent-graft migration and another owing to dissection prior to hospital discharge. Mortality after open surgery was 46% (12/26) versus 13% (2/15) in the EVAR group (p>0.05). Univariate analysis without considering variables other than mortality resulted in OR 5.4 (95% CI 0.9 to 58; p=0.07). Considering risk factors and shock, multivariate analysis resulted in OR 6.5 (95% CI 0.8 to 96; p=0.08). In the EVAR group, 60% (9/15) had complications; in the group with open surgery, the complication rate was 85% (22/26; p=0.13).

It is possible to treat rAAA with EVAR. Hypotensive patients can, at least initially, be operated under local anesthesia to stabilize blood pressure utilizing a percutaneously inserted occlusion balloon. There was a trend in our study for reduced mortality and morbidity with EVAR, but further studies are required to conclude whether EVAR significantly increases survival and reduces complications.