Benefits of an Endovascular-First Protocol for Management of Ruptured Abdominal Aortic Aneurysm

Study Questions:

What are the outcomes associated with an endovascular-first protocol for management of patients with a ruptured abdominal aortic aneurysm (rAAA)?

Methods:

This was a retrospective nonrandomized intention-to-treat cohort study of consecutive patients presenting to a single academic medical center with a rAAA before (1997-2006) and after (2007-2014) implementation of an endovascular-first treatment strategy. Primary outcome measures were 30-day mortality, discharge disposition, and overall survival at latest follow-up.

Results:

A total of 88 patients with rAAA were treated during the study period (46 in the pre- and 42 in the post-endovascular aneurysm repair [EVAR] intention-to-treat protocol groups). Nine patients died intraoperatively (5.9% who underwent an EVAR vs. 13.0% who underwent an open repair; p = 0.47). Although 30-day mortality during the pre- and post-protocol periods was 32.6% and 14.3% (p = 0.03), respectively, there was no significant difference in 30-day mortality based on treatment type (27.4% for open repair vs. 23.5% for EVAR; p > 0.99). Significantly fewer patients during the post- than during the pre-protocol period experienced one or more major complications (45% vs. 71.8%, p = 0.02). More patients undergoing open repair than undergoing EVAR experienced one or more major complications (69.6% vs. 43.8%; p = 0.04). One-, 3-, and 5-year survival rates were 50.0%, 45.7%, and 39.1% for open repair, respectively, and 61.9%, 42.9%, and 23.8% for ruptured EVAR (rEVAR), respectively.

Conclusions:

The authors concluded that an endovascular-first protocol for the treatment of rAAA is associated with decreased perioperative morbidity and mortality.

Perspective:

Although there are multiple limitations to this study (lack of randomization, small sample size, and retrospective nature), the authors highlight the potential benefits of an endovascular-first protocol for management of patients with rAAA. As the authors acknowledge, the improved outcomes in the post-protocol patients may be a “reflection of not simply the decreased use of rEVAR, but, rather, the net effect of complementing the integration of an endovascular-first approach with a more comprehensive structured protocol for patients with a rAAA.”

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Vascular Medicine, Aortic Surgery, Interventions and Vascular Medicine

Keywords: Aortic Aneurysm, Abdominal, Aortic Rupture, Cardiac Surgical Procedures, Endovascular Procedures, Outcome Assessment (Health Care), Survival Rate


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