Surgical and endovascular repair of ruptured abdominal aortic aneurysm
- Ellen D Dillavou, MD
Ellen D Dillavou, MD
- Associate Professor of Vascular Surgery
- Duke University Medical Center
- Section Editors
- Joseph L Mills, Sr, MD
Joseph L Mills, Sr, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor and Chief
- Division of Vascular Surgery and Endovascular Therapy
- Baylor College of Medicine
- John F Eidt, MD
John F Eidt, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor of Surgery, Texas A&M Health Sciences Center - Dallas Campus
- Vice Chair of Vascular Surgical Services, Baylor Heart and Vascular Hospital at Dallas
Rupture is a fatal complication of abdominal aortic aneurysm. An aneurysm is defined as ruptured when bleeding is present outside of the wall of the aneurysm. Elective aneurysm repair is associated with low rates of morbidity and mortality in properly selected individuals, but in spite of advances in intensive care unit management and techniques for repair, mortality following repair of ruptured abdominal aortic aneurysm (ruptured AAA) remains high . Surgical outcomes may be improved using endovascular aneurysm repair (EVAR), but aortic endografting under emergency circumstances presents many challenges. Increasing numbers of institutions have initiated protocols for endovascular repair of ruptured AAA with promising results in small series, but not all institutions are equipped to treat all ruptured AAAs using minimally-invasive technology. However, transfer of the patient with ruptured AAA may be associated with increased mortality (17 to 19 percent) compared with those who undergo repair at the institution where they present [2,3].
Specific considerations for the surgical and endovascular repair of emergent AAA repair will be reviewed here. General techniques for AAA repair are discussed elsewhere. The diagnosis and management of AAA and ruptured AAA are discussed in separate topic reviews. (See "Endovascular repair of abdominal aortic aneurysm" and "Open surgical repair of abdominal aortic aneurysm" and "Management of asymptomatic abdominal aortic aneurysm", section on 'Introduction' and "Management of symptomatic (non-ruptured) and ruptured abdominal aortic aneurysm", section on 'Introduction'.)
OPEN SURGICAL VERSUS ENDOVASCULAR REPAIR
Significant differences in mortality rates for open compared with endovascular repair for ruptured aneurysm have not definitively been demonstrated. There is some evidence to suggest that perioperative (30 day) outcomes for endovascular aneurysm repair (EVAR) following ruptured AAA (abdominal aortic aneurysm) may be better than for open AAA repair [4-12]. Thus, for patients with multiple risk factors for a poor prognosis following open surgical repair, and anatomy suitable for an endovascular approach, we suggest an attempt at EVAR, provided appropriately experienced personnel and equipment are available. However, as promising as EVAR appears to be for the treatment of ruptured AAA, logistical and practical barriers need to be overcome to more uniformly offer EVAR for repair of ruptured AAA. (See "Management of symptomatic (non-ruptured) and ruptured abdominal aortic aneurysm", section on 'Decision for patient transfer'.)
In observational studies, endovascular repair of ruptured AAA has been associated with lower mortality rates compared with open repair of ruptured AAA (EVAR: 16 to 31 percent; open 34 to 44 percent), which may be due to decreased blood loss and decreased ischemia [1,6,11,13-22]. In a systematic review, the pooled odds ratio for death after EVAR compared with open repair was 0.44 (95% CI 0.37-0.53) in observational studies, and 0.54 (95% CI 0.47-0.62) among administrative registries . The main criticism of these studies is that hemodynamically stable patients with ruptured AAA are more often selected for EVAR, and hemodynamically unstable patients tend to get treated with open repair . Some have suggested that such patient selection biases the comparison, and that the mortality rate for EVAR and open repair for ruptured AAA are actually similar . In support of this idea was a comparison of morphologic variables among 458 patients in the IMPROVE trial  (discussed below) who underwent open or endovascular repair . Short aneurysm neck adversely affected mortality after open repair of ruptured AAA (an exclusion criteria for EVAR), which helps explain why observational studies, and not randomized trials (discussed in the next paragraph), show an early survival benefit.
Several randomized trials have compared open repair versus EVAR in patients with ruptured AAA [11,26-33]. The first was a small, pilot study that reported a high mortality rate of 53 percent for both groups, prompting widespread criticism of the trial design . A larger, Dutch trial randomly assigned 132 patients who were anatomically suitable for either repair similarly and found no difference in perioperative (30 day) mortality between those who received open repair versus EVAR (25 versus 21 percent) . It was suggested that anatomic suitability for EVAR related to favorable neck anatomy (ie, a long aneurysm neck) may confer a survival advantage, even in patients treated with open repair. A later French trial included 107 patients and also reported similar morbidity and mortality for open versus endovascular repair (30 day: 24 versus 18 percent; one year: 35 versus 30 percent) .
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- OPEN SURGICAL VERSUS ENDOVASCULAR REPAIR
- CRITERIA FOR ENDOVASCULAR REPAIR
- OPEN SURGICAL REPAIR
- Aortic control
- Handling the inferior mesenteric artery
- ENDOVASCULAR REPAIR
- Aortic control and graft placement
- Conversion to open surgery
- FOLLOW-UP IMAGING
- SUMMARY AND RECOMMENDATIONS