Comparative predictors of mortality for endovascular and open repair of ruptured infrarenal abdominal aortic aneurysms

Timur P Sarac, Mohsen Bannazadeh, A F Rowan, James Bena, Sunita Srivastava, Mathew Eagleton, Sean Lyden, Daniel G Clair, Vikram Kashyap
Annals of Vascular Surgery 2011, 25 (4): 461-8

BACKGROUND: The continued success of elective endovascular aneurysm repair (EVAR) has led to an extension of this technology to ruptured aortas. The purpose of this study was to evaluate our results of ruptured infrarenal aortic aneurysm (rAAA).

METHODS: The treatment results of all patients who underwent repair of rAAAs between January 1990 and May 2008 were reviewed retrospectively. Comorbidities, intraoperative details, and postoperative complications were tabulated. EVAR and open repair were compared.

RESULTS: Between January 1990 and May 2008, 160 patients underwent repair of rAAA. Of these, 32 (20%) underwent EVAR for rAAA; of 160 patients, 112 were considered to have free rupture (70%) and 48 had contained rupture (30%). The average Acute Physiology and Chronic Health Evaluation II score was 13.3 ± 6.7. The Kaplan-Meier survival rates at 30 days, 6 months, 1 year, and 5 years were 69% (62,77), 57% (50,65), 50% (43,59), and 25% (19,34), respectively, with no difference seen in EVAR group as compared with open surgery (p = 0.24). Intraoperative mortality was 5.6%, with no patient undergoing EVAR suffering an intraoperative death (p = 0.03). However, 30-day mortality was 31.9% with no difference between EVAR and open surgery (31.2% vs. 32%; p = 0.93) results. Multivariate analysis for 30-day mortality found renal insufficiency (RI) odds ratio (OR): 2.4 (1.1, 5.3), p = 0.04; hypotension OR: 2.4 (1.1, 5.3), p = 0.02; and cardiac arrest OR: 3.8 (1.1, 11.6, p = 0.03), were all associated with the greatest mortality. Of all predictors analyzed, multivariate analysis found preoperative RI OR: 2.32 (1.55, 3.47), p < 0.001, was the only independent predictor of decreased long-term survival.

CONCLUSIONS: Mortality rates for rAAA remain high. The use of EVAR for these procedures equals that for open repair with regard to 30-day and long-term mortality. Preoperative cardiac arrest and RI were associated with inferior results for both EVAR and open repair. Clinical judgment on when to use EVAR as a primary repair modality must be exercised.

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