Manish Mehta, Benjamin Burton, John Byrne, Philip S. Paty, John B. Taggert, Sean P. Roddy, Paul B. Kreienberg, R. Clement Darling
The Vascular Group, The Institute for Vascular Health and Disease, Albany Medical College, The Center for Vascular Awareness Inc, Albany, NY
OBJECTIVES: During EVAR for ruptured AAA (r-AAA), inadequate aortic neck morphology often requires surgeons to expand the stent graft “indications for use” (IFU). This is the first study to date that evaluates outcomes of patients with r-AAA that underwent EVAR with favorable aortic neck (f-AN) vs. hostile aortic neck (h-AN), vs. open surgical repair (OSR).
METHODS: Over a 5-year period, 180 patients with r-AAA underwent EVAR (n=74, 41.1%) or OSR (n=106, 58.9%). The 74 r-EVAR patients were divided into 2 groups based on f-AN (n=25, 33.7%) vs. h-AN (n=49, 66.7%) morphology. Data was collected prospectively, and aortic neck measurements were standardized relative to the IFUs of particular stent graft. Patients were analyzed on an intention-to-treat basis and outcomes were evaluated by logistic regression multivariable analysis.
RESULTS: The 30-day mortality was the lowest in r-EVAR patients with f-AN and the highest in the OSR patients (f-AN 8%; h-AN 23%; OSR 43.4%; p<0.01), and both f-AN and h-AN r-EVAR patients had a better cumulative 3-year survival than OSR (f-AN 64%, h-AN 67%, OSR 44%, p<0.01). The r-EVAR patients with h-AN had a significantly higher incidence of female gender (32% vs. 19%, p<0,05), mean maximum AAA diameter (7.4cm vs. 5.5cm, p<0.05), abdominal compartment syndrome (ACS) (20% vs. 4%, p<0.05), Type I endoleaks (16% vs. 4%, p<0.05), and the need for all secondary interventions (77% vs. 40%, p<0.05).
CONCLUSIONS: For r-AAA, although EVAR provides the greatest benefit to patients with f-AN, even patients with h-AN experience a survival benefit at 3 years when compared to OSR. However, r-EVAR patients with h-AN experience a higher incidence of ACS, Type I endoleaks, and secondary interventions, and mandate vigilant follow-up.
AUTHOR DISCLOSURES: B. Burton: Nothing to disclose; J. Byrne: Nothing to disclose; R. Darling: Nothing to disclose; P. B. Kreienberg: Nothing to disclose; M. Mehta: W.L. Gore and Associates, Medtronic Inc, Aptus Endosystems, Lombard Medical Technologies, Bolton Medical, Abbott Vascular, Cordis Corporateion, Terumo Cardiovascular, Ev3 Endovascular, Trivascular Inc, Maquet Cardiovascular, Harvest Technologies, Research Grants W.L. Gore and Associates, Ev3 Endovascular, Cordis Corporation, Trivascular Inc, Consulting fees or other remuneration payment); P. S. Paty: Nothing to disclose; S. P. Roddy: Nothing to disclose; J. B. Taggert: Nothing to disclose..
Posted April 2013