EVAR for Unstable Patients With Ruptured AAA Shown to Outperform Surgery

December 4, 2014—A study comparing open surgery (OS) versus endovascular aneurysm repair (EVAR) of unstable patients with ruptured abdominal aortic aneurysms (rAAA), was published by Prateek K. Gupta, MD, et al in the Journal of Vascular Surgery (2014;60:1439–1445). The study data were first presented at the 2013 Vascular Annual Meeting of the Society for Vascular Surgery held May 30 to June 1, 2013, in San Francisco, California.

The objective of this study was to compare 30-day outcomes in patients undergoing OS versus EVAR for all rAAAs, focusing specifically on patients with instability.

As noted by the investigators in the Journal of Vascular Surgery, two randomized trials to date have compared OS and EVAR for rAAA; however, neither addressed optimal management of unstable patients. Additionally, single-center reports have produced conflicting data regarding the superiority of one approach versus the other, with the lack of statistical power due to low patient numbers. Previous studies have also not delineated between the outcomes of stable patients with a contained rupture versus those patients with instability.

The study identified patients who underwent repair of rAAA from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database from 2005 to 2010, in which approximately one-third of patients treated for rAAA underwent EVAR in NSQIP-participating hospitals.

The investigators stated that, not surprisingly, they found that unstable patients have less favorable outcomes, and that in both stable and unstable rAAA patients, EVAR is associated with a diminished 30-day mortality and morbidity.

The study identified unstable patients with rAAA as those who were American Society of Anesthesiologists Physical Status Classification 4 or 5 requiring emergency repair with at least one of the following: preoperative shock, preoperative transfusion of > 4 units, preoperative intubation, or preoperative coma or impaired sensorium. Univariable and multivariable logistic regression analyses were performed.

Of the 1,447 patients who were evaluated, 65.5% underwent OS and 34.5% underwent EVAR. For the 45% of those patients who were unstable, OS was performed in 71.3% and EVAR in 28.7%. The 30-day mortality rate was 47.9% (OS, 52.8%; EVAR, 35.6%; P < .0001) for unstable rAAAs and was 22.4% for stable rAAAs (OS, 26.3%; EVAR, 16.4%; P = .001). Among patients with unstable rAAA, 26% had a myocardial infarction or cardiac arrest in ≤ 30 days (OS, 29.0%; EVAR, 19.1%; P = .006), and 17% needed postoperative dialysis (OS, 18.7%; EVAR, 12.8%; P = .04). Among patients with stable rAAA, 13.6% had a myocardial infarction or cardiac arrest in ≤ 30 days (OS, 14.9%; EVAR, 11.6%; P = .20), and 11.5% needed postoperative dialysis (OS, 13.3%; EVAR, 8.7%; P = .047). Multivariable analyses showed OS was a predictor of 30-day mortality for unstable rAAA (odds ratio, 1.74; 95% confidence interval, 1.16-2.62) and stable rAAA (odds ratio, 1.64; 95% confidence interval, 1.1–2.43), reported the investigators in the Journal of Vascular Surgery.