Endo Repair of Ruptured AAA--Good Short-Term Results

BY MICHELE G. SULLIVAN

NEW ORLEANS -- Surgeons are increasingly turning to endovascular repair of ruptured abdominal aortic aneurysms, with better short-term patient outcomes than have been seen in open repair, according to a database review presented at the annual clinical congress of the American College of Surgeons.

"We found a consistent change in the national trends of surgical repair of AAA, with endovascular repair increasing steadily since 2001," Dr. Kelly Lesperance said. "Endovascular repair was associated with lower mortality, improved discharge disposition, and shorter hospital length of stay."

The biggest mortality benefit occurred when endovascular repair (EVAR) was performed at a teaching hospital, said Dr. Lesperance, a captain in the U.S. Army. "We found that benefit was lost when the repair was done at a nonteaching hospital."

Dr. Lesperance presented a retrospective review conducted by Dr. Matthew Martin, a colleague in the surgery department at Madigan Army Medical Center, Tacoma, Wash. Dr. Martin is currently serving as chief of trauma with the 28th Combat Support Hospital in Baghdad, Iraq.

Data from the Nationwide Inpatient Sample was used for the study. The researchers identified 19,500 patients who underwent a surgical abdominal aortic aneurysm (AAA) repair from 2001 through 2004. Of those, 18,000 procedures were open, and 1,500 were endovascular.

The number of endovascular repairs rose steadily over the study period, from 6% in 2001 to 11% in 2004. Mortality for all ruptured AAAs remained constant, however, hovering at about 50% over the years.

Overall, in-hospital mortality rates continued to improve with EVAR. In 2001, open-repair mortality was actually slightly better than EVAR mortality (40% vs. 43%), but by 2002, EVAR mortality was significantly better, and its benefit rose annually. (See chart.)

More EVAR patients than open repair patients were discharged home in each of the study years. In 2001, the difference was small (33% EVAR vs. 27% open), but it increased significantly by 2002 (43% vs. 24%) and remained steady throughout the study period.

Conversely, more open repair patients were discharged to a skilled nursing or rehabilitation facility. In 2001, an equal percentage of patients were discharged to such a facility for both techniques (33%), but by 2002, the difference was significant (23% EVAR vs. 43% open repair), and those numbers remained steady. Patients who were not discharged home or to a skilled nursing/rehabilitation facility were transferred to other facilities, including another hospital, a ventilator rehabilitation center, or another inpatient setting.

A subanalysis was performed of the 2003-2004 data, during which time 10,000 ruptured AAAs were repaired--1,000 with EVAR and 9,000 with open surgery. There was no difference in average patient age between the two groups (73 years). However, patients undergoing open repair had more comorbid illness and greater disease severity. "We saw that the healthier patients were undergoing EVAR and the sicker ones tended to have open repair."

The 2003-2004 data also showed that EVAR was associated with shorter length of stay than open surgery (mean 9 vs. 13 days) and more patients discharged home (69% vs. 37%). During this period, there was a cost benefit, with total hospital charges for EVAR averaging $97,000, compared with $110,000 for open repair.

There was a significant survival benefit when EVAR was performed at a teaching hospital: 21% EVAR mortality versus 38% open mortality. Mortality rates at a nonteaching hospital were 55% for EVAR, 46% for open.