Endovascular treatment of ruptured abdominal aortic aneurysm: is there a long-term benefit at follow-up?

AIM: Several studies have shown the feasibility of endovascular repair of ruptured abdominal aortic aneurysms (rEVAR). However, the role and value of rEVAR remains controversial due to selection bias and lack of long-term results. In the present study we describe our short- and long-term results of treating patients with rEVAR irrespective of hemodynamic condition and challenging anatomy.

METHODS: In April 2006 we started the single centre prospective non-randomised Ruptured Aneurysm Study (RASA). During a four year enrolment period all consecutive patients presenting with infrarenal ruptured AAA (rAAA, N.=117) were assessed for preferential rEVAR treatment. A rAAA was defined as extravasation of blood or hematoma outside the AAA due to transmural tear in the infrarenal abdominal aorta wall documented by preoperative computed tomography (CT) angiography examination or during open repair. Patients with challenging anatomy (infrarenal neck length below 15 mm and neck angulation above 60 degrees) were included as part of a damage control concept. Complication and mortality rates were studied at 30 days and yearly afterwards.

RESULTS: Thirty-five patients (33% of all admitted rAAA) were treated with rEVAR and 42% of them were considered hemodynamically unstable (systolic blood pressure <100 mmHg) and 30% had challenging AAA anatomy. The mortality rate at 30 days in the rEVAR group was 17%, in the open repair group 31%, and in the entire rAAA group (including abstained patients) 36%. During the first 30 days, 18 rEVAR patients experienced complications with nine re-interventions as a result. Long-term mortality of the rEVAR patients was 34% after a median follow-up of 3.4 years. All deaths after one year follow-up were non-AAA related. Multivariate analysis shows that Hardman index, presence of peripheral arterial obstructive disease and lowest systolic blood pressure during surgery are independently associated with long-term survival. Challenging rAAA anatomy was not associated with impaired survival.

CONCLUSION: Our study shows that rEVAR is feasible irrespective of hemodynamic condition and that it is associated with relative low mortality rates. Challenging rAAA anatomy may not affect overall long-term survival, but six out of ten patients remain unsuitable for rEVAR because of inappropriate anatomy.