Endovascular Versus Open Surgical Repair Of Ruptured Abdominal Aortic Aneurysms In Hemodynamically Stable And Unstable Patients: Midterm Outcomes Of A 5-Year Prospective Intent-To-Treat Study

Manish Mehta, Sean P. Roddy, Yaron Sternbach, Philip SK Paty, Paul B. Kreienberg, Kathleen J. Ozsvath, John B. Taggert, Benjamin B. Chang, Dhiraj M. Shah, R Clement Darling, III.
Albany Medical College, Albany, NY.

OBJECTIVES: Despite improvements in perioperative diagnosis, treatment, and postoperative care, surgical repair of ruptured abdominal aortic aneurysms (r-AAA) continues to have a high morbidity and mortality. In this intent-to-treat study, we compare our results of endovascular verses open surgical repair for all r-AAA over a 5 year period.

METHODS: From January 2002 to January 2007, 145 patients presented to our institution with r-AAA and underwent repair via endovascular (n=66, 44%) or open surgical approach (n=81, 56%). Thirty-seven patients (endovascular: n=16, 25%; open surgical: n=21, 26%) were considered hemodynamically unstable on arrival, and preoperative CT scan was not deemed necessary for all patients to undergo endovascular repair. Data was prospectively collected in the vascular registry and statistical analysis was performed using Chi square and life table methods.

RESULTS: The utilization of endovascular techniques for treating r-AAA increased over time (2002, 13%; 2003, 45%; 2004, 60%; 2005, 65%; 2006, 71%; P<0.05). When compared to the open surgical group, the endovascular group had significantly higher preexisting co-morbidities (CAD: 67% vs. 44%, p<0.05; COPD: 28% vs. 12%, p<0.05; CRI: 19% vs. 8%, p<0.05), and lower 30-day mortality (17% vs. 40%, p<0.05). Overall mortality was similar in hemodynamically stable and unstable patients. Of patients with initial endovascular repair, 3 (5%) required ‘on-table’ conversion to open surgical repair (1 patient without a preoperative CT scan), and 1 (2%) underwent elective conversion to open surgical repair. Life table analysis indicated the cumulative survival rate for the endovascular group (1 year, 80%; 2 year, 72%; 3 year, 64%; 4 year, 64%; 5 year, 64%) was substantially better than for the open surgical group (1 year, 58%; 2 year, 52%; 3 year, 45%; 4 year, 39%; 5 year, 39%).

CONCLUSIONS: Endovascular repair of r-AAA is associated with markedly reduced mortality and improved midterm survival when compared to the open surgical approach. With increasing experience and a standardized approach, hemodynamically stable as well as unstable patients with r-AAA can be treated by endovascular means, and a preoperative CT scan may not be an absolute necessity.