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 Science Center
- 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) .
- Dillavou ED, Muluk SC, Makaroun MS. A decade of change in abdominal aortic aneurysm repair in the United States: Have we improved outcomes equally between men and women? J Vasc Surg 2006; 43:230.
- Mell MW, Wang NE, Morrison DE, Hernandez-Boussard T. Interfacility transfer and mortality for patients with ruptured abdominal aortic aneurysm. J Vasc Surg 2014; 60:553.
- Brattheim BJ, Eikemo TA, Altreuther M, et al. Regional disparities in incidence, handling and outcomes of patients with symptomatic and ruptured abdominal aortic aneurysms in Norway. Eur J Vasc Endovasc Surg 2012; 44:267.
- Li Y, Li Z, Wang S, et al. Endovascular versus Open Surgery Repair of Ruptured Abdominal Aortic Aneurysms in Hemodynamically Unstable Patients: Literature Review and Meta-Analysis. Ann Vasc Surg 2016; 32:135.
- van Beek SC, Conijn AP, Koelemay MJ, Balm R. Editor's Choice - Endovascular aneurysm repair versus open repair for patients with a ruptured abdominal aortic aneurysm: a systematic review and meta-analysis of short-term survival. Eur J Vasc Endovasc Surg 2014; 47:593.
- Veith FJ, Lachat M, Mayer D, et al. Collected world and single center experience with endovascular treatment of ruptured abdominal aortic aneurysms. Ann Surg 2009; 250:818.
- IMPROVE Trial, Powell JT, Thompson SG, et al. The Immediate Management of the Patient with Rupture: Open Versus Endovascular repair (IMPROVE) aneurysm trial--ISRCTN 48334791 IMPROVE trialists. Acta Chir Belg 2009; 109:678.
- Ten Bosch JA, Teijink JA, Willigendael EM, Prins MH. Endovascular aneurysm repair is superior to open surgery for ruptured abdominal aortic aneurysms in EVAR-suitable patients. J Vasc Surg 2010; 52:13.
- Ricotta JJ 2nd, Malgor RD, Oderich GS. Ruptured endovascular abdominal aortic aneurysm repair: part II. Ann Vasc Surg 2010; 24:269.
- Coppi G, Gennai S, Saitta G, et al. Treatment of ruptured abdominal aortic aneurysm after endovascular abdominal aortic repair: A comparison with patients without prior treatment. J Vasc Surg 2009; 49:582.
- IMPROVE Trial Investigators, Powell JT, Sweeting MJ, et al. Endovascular or open repair strategy for ruptured abdominal aortic aneurysm: 30 day outcomes from IMPROVE randomised trial. BMJ 2014; 348:f7661.
- Mohan PP, Hamblin MH. Comparison of endovascular and open repair of ruptured abdominal aortic aneurysm in the United States in the past decade. Cardiovasc Intervent Radiol 2014; 37:337.
- Thomas DM, Hulten EA, Ellis ST, et al. Open versus Endovascular Repair of Abdominal Aortic Aneurysm in the Elective and Emergent Setting in a Pooled Population of 37,781 Patients: A Systematic Review and Meta-Analysis. ISRN Cardiol 2014; 2014:149243.
- Speicher PJ, Barbas AS, Mureebe L. Open versus endovascular repair of ruptured abdominal aortic aneurysms. Ann Vasc Surg 2014; 28:1249.
- Starnes BW, Quiroga E, Hutter C, et al. Management of ruptured abdominal aortic aneurysm in the endovascular era. J Vasc Surg 2010; 51:9.
- McPhee J, Eslami MH, Arous EJ, et al. Endovascular treatment of ruptured abdominal aortic aneurysms in the United States (2001-2006): a significant survival benefit over open repair is independently associated with increased institutional volume. J Vasc Surg 2009; 49:817.
- Chagpar RB, Harris JR, Lawlor DK, et al. Early mortality following endovascular versus open repair of ruptured abdominal aortic aneurysms. Vasc Endovascular Surg 2010; 44:645.
- Lesperance K, Andersen C, Singh N, et al. Expanding use of emergency endovascular repair for ruptured abdominal aortic aneurysms: disparities in outcomes from a nationwide perspective. J Vasc Surg 2008; 47:1165.
- Mureebe L, Egorova N, Giacovelli JK, et al. National trends in the repair of ruptured abdominal aortic aneurysms. J Vasc Surg 2008; 48:1101.
- Davenport DL, O'Keeffe SD, Minion DJ, et al. Thirty-day NSQIP database outcomes of open versus endoluminal repair of ruptured abdominal aortic aneurysms. J Vasc Surg 2010; 51:305.
- Ali MM, Flahive J, Schanzer A, et al. In patients stratified by preoperative risk, endovascular repair of ruptured abdominal aortic aneurysms has a lower in-hospital mortality and morbidity than open repair. J Vasc Surg 2015; 61:1399.
- Mehta M, Byrne J, Darling RC 3rd, et al. Endovascular repair of ruptured infrarenal abdominal aortic aneurysm is associated with lower 30-day mortality and better 5-year survival rates than open surgical repair. J Vasc Surg 2013; 57:368.
- Dubois L, Mayer D, Rancic Z, et al. Debate: whether endovascular repair offers a survival advantage over open repair for ruptured abdominal aortic aneurysms. J Vasc Surg 2015; 61:546.
- Takagi H, Kawai N, Umemoto T. Regarding "Endovascular repair of ruptured abdominal aortic aneurysms". J Vasc Surg 2008; 48:253.
- IMPROVE Trial Investigators. The effect of aortic morphology on peri-operative mortality of ruptured abdominal aortic aneurysm. Eur Heart J 2015; 36:1328.
- Wallace GA, Starnes BW, Hatsukami TS, et al. Favorable discharge disposition and survival after successful endovascular repair of ruptured abdominal aortic aneurysm. J Vasc Surg 2013; 57:1495.
- IMPROVE Trial Investigators. Endovascular strategy or open repair for ruptured abdominal aortic aneurysm: one-year outcomes from the IMPROVE randomized trial. Eur Heart J 2015; 36:2061.
- IMPROVE trial investigators, Powell JT, Hinchliffe RJ, et al. Observations from the IMPROVE trial concerning the clinical care of patients with ruptured abdominal aortic aneurysm. Br J Surg 2014; 101:216.
- Hinchliffe RJ, Bruijstens L, MacSweeney ST, Braithwaite BD. A randomised trial of endovascular and open surgery for ruptured abdominal aortic aneurysm - results of a pilot study and lessons learned for future studies. Eur J Vasc Endovasc Surg 2006; 32:506.
- Reimerink JJ, Hoornweg LL, Vahl AC, et al. Endovascular repair versus open repair of ruptured abdominal aortic aneurysms: a multicenter randomized controlled trial. Ann Surg 2013; 258:248.
- Desgranges P, Kobeiter H, Katsahian S, et al. Editor's Choice - ECAR (Endovasculaire ou Chirurgie dans les Anévrysmes aorto-iliaques Rompus): A French Randomized Controlled Trial of Endovascular Versus Open Surgical Repair of Ruptured Aorto-iliac Aneurysms. Eur J Vasc Endovasc Surg 2015; 50:303.
- Hoornweg LL, Wisselink W, Vahl A, et al. The Amsterdam Acute Aneurysm Trial: suitability and application rate for endovascular repair of ruptured abdominal aortic aneurysms. Eur J Vasc Endovasc Surg 2007; 33:679.
- Sweeting MJ, Ulug P, Powell JT, et al. Ruptured Aneurysm Trials: The Importance of Longer-term Outcomes and Meta-analysis for 1-year Mortality. Eur J Vasc Endovasc Surg 2015; 50:297.
- Antoniou GA, Georgiadis GS, Antoniou SA, et al. Endovascular repair for ruptured abdominal aortic aneurysm confers an early survival benefit over open repair. J Vasc Surg 2013; 58:1091.
- von Meijenfeldt GC, Ultee KH, Eefting D, et al. Differences in mortality, risk factors, and complications after open and endovascular repair of ruptured abdominal aortic aneurysms. Eur J Vasc Endovasc Surg 2014; 47:479.
- Prinssen M, Verhoeven EL, Buth J, et al. A randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms. N Engl J Med 2004; 351:1607.
- EVAR trial participants. Endovascular aneurysm repair versus open repair in patients with abdominal aortic aneurysm (EVAR trial 1): randomised controlled trial. Lancet 2005; 365:2179.
- Lederle FA, Freischlag JA, Kyriakides TC, et al. Outcomes following endovascular vs open repair of abdominal aortic aneurysm: a randomized trial. JAMA 2009; 302:1535.
- Becquemin JP, Pillet JC, Lescalie F, et al. A randomized controlled trial of endovascular aneurysm repair versus open surgery for abdominal aortic aneurysms in low- to moderate-risk patients. J Vasc Surg 2011; 53:1167.
- Tambyraja AL, Murie JA, Chalmers RT. Prediction of outcome after abdominal aortic aneurysm rupture. J Vasc Surg 2008; 47:222.
- Mell MW, O'Neil AS, Callcut RA, et al. Effect of early plasma transfusion on mortality in patients with ruptured abdominal aortic aneurysm. Surgery 2010; 148:955.
- Reimerink JJ, Hoornweg LL, Vahl AC, et al. Controlled hypotension in patients suspected of a ruptured abdominal aortic aneurysm: feasibility during transport by ambulance services and possible harm. Eur J Vasc Endovasc Surg 2010; 40:54.
- Chang BB, Shah DM, Paty PS, et al. Can the retroperitoneal approach be used for ruptured abdominal aortic aneurysms? J Vasc Surg 1990; 11:326.
- Johnston KW. Ruptured abdominal aortic aneurysm: six-year follow-up results of a multicenter prospective study. Canadian Society for Vascular Surgery Aneurysm Study Group. J Vasc Surg 1994; 19:888.
- Piotrowski JJ, Ripepi AJ, Yuhas JP, et al. Colonic ischemia: the Achilles heel of ruptured aortic aneurysm repair. Am Surg 1996; 62:557.
- Eliason JL, Wainess RM, Dimick JB, et al. The effect of secondary operations on mortality following abdominal aortic aneurysm repair in the United States: 1988-2001. Vasc Endovascular Surg 2005; 39:465.
- Cho JS, Kim JY, Rhee RY, et al. Contemporary results of open repair of ruptured abdominal aortoiliac aneurysms: effect of surgeon volume on mortality. J Vasc Surg 2008; 48:10.
- Mehta M, Taggert J, Darling RC 3rd, et al. Establishing a protocol for endovascular treatment of ruptured abdominal aortic aneurysms: outcomes of a prospective analysis. J Vasc Surg 2006; 44:1.
- Setacci F, Sirignano P, De Donato G, et al. Endovascular approach for ruptured abdominal aortic aneursyms. J Cardiovasc Surg (Torino) 2010; 51:313.
- Arthurs ZM, Sohn VY, Starnes BW. Ruptured abdominal aortic aneurysms: remote aortic occlusion for the general surgeon. Surg Clin North Am 2007; 87:1035.
- Assar AN, Zarins CK. Endovascular proximal control of ruptured abdominal aortic aneurysms: the internal aortic clamp. J Cardiovasc Surg (Torino) 2009; 50:381.
- Mayer D, Pfammatter T, Rancic Z, et al. 10 years of emergency endovascular aneurysm repair for ruptured abdominal aortoiliac aneurysms: lessons learned. Ann Surg 2009; 249:510.
- Philipsen TE, Hendriks JM, Lauwers P, et al. The use of rapid endovascular balloon occlusion in unstable patients with ruptured abdominal aortic aneurysm. Innovations (Phila) 2009; 4:74.
- Arthurs Z, Starnes B, See C, Andersen C. Clamp before you cut: Proximal control of ruptured abdominal aortic aneurysms using endovascular balloon occlusion--Case reports. Vasc Endovascular Surg 2006; 40:149.
- Malina M, Veith F, Ivancev K, Sonesson B. Balloon occlusion of the aorta during endovascular repair of ruptured abdominal aortic aneurysm. J Endovasc Ther 2005; 12:556.
- Raux M, Marzelle J, Kobeiter H, et al. Endovascular balloon occlusion is associated with reduced intraoperative mortality of unstable patients with ruptured abdominal aortic aneurysm but fails to improve other outcomes. J Vasc Surg 2015; 61:304.
- Moulakakis KG, Dalainas I, Mylonas S, et al. Conversion to open repair after endografting for abdominal aortic aneurysm: a review of causes, incidence, results, and surgical techniques of reconstruction. J Endovasc Ther 2010; 17:694.
- Drury D, Michaels JA, Jones L, Ayiku L. Systematic review of recent evidence for the safety and efficacy of elective endovascular repair in the management of infrarenal abdominal aortic aneurysm. Br J Surg 2005; 92:937.
- Alonso-Pérez M, Segura RJ, Sánchez J, et al. Factors increasing the mortality rate for patients with ruptured abdominal aortic aneurysms. Ann Vasc Surg 2001; 15:601.
- Tøttrup M, Fedder AM, Jensen RH, et al. The value of routine flexible sigmoidoscopy within 48 hours after surgical repair of ruptured abdominal aortic aneurysms. Ann Vasc Surg 2013; 27:714.
- Karkos CD, Menexes GC, Patelis N, et al. A systematic review and meta-analysis of abdominal compartment syndrome after endovascular repair of ruptured abdominal aortic aneurysms. J Vasc Surg 2014; 59:829.
- Sörelius K, Wanhainen A, Acosta S, et al. Open abdomen treatment after aortic aneurysm repair with vacuum-assisted wound closure and mesh-mediated fascial traction. Eur J Vasc Endovasc Surg 2013; 45:588.
- Bown MJ, Sutton AJ, Bell PR, Sayers RD. A meta-analysis of 50 years of ruptured abdominal aortic aneurysm repair. Br J Surg 2002; 89:714.
- Hoornweg LL, Storm-Versloot MN, Ubbink DT, et al. Meta analysis on mortality of ruptured abdominal aortic aneurysms. Eur J Vasc Endovasc Surg 2008; 35:558.
- Bengtsson H, Bergqvist D. Ruptured abdominal aortic aneurysm: a population-based study. J Vasc Surg 1993; 18:74.
- Cho JS, Park T, Kim JY, et al. Prior endovascular abdominal aortic aneurysm repair provides no survival benefits when the aneurysm ruptures. J Vasc Surg 2010; 52:1127.
- Schlösser FJ, Vaartjes I, van der Heijden GJ, et al. Mortality after hospital admission for ruptured abdominal aortic aneurysm. Ann Vasc Surg 2010; 24:1125.
- Biancari F, Mazziotti MA, Paone R, et al. Outcome after open repair of ruptured abdominal aortic aneurysm in patients>80 years old: a systematic review and meta-analysis. World J Surg 2011; 35:1662.
- Gupta PK, Ramanan B, Engelbert TL, et al. A comparison of open surgery versus endovascular repair of unstable ruptured abdominal aortic aneurysms. J Vasc Surg 2014; 60:1439.
- Cho JS, Gloviczki P, Martelli E, et al. Long-term survival and late complications after repair of ruptured abdominal aortic aneurysms. J Vasc Surg 1998; 27:813.
- Kazmers A, Perkins AJ, Jacobs LA. Aneurysm rupture is independently associated with increased late mortality in those surviving abdominal aortic aneurysm repair. J Surg Res 2001; 95:50.
- 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