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)?


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.


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.


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


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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