Endovascular Repair Ups Survival of Patients with Ruptured AAA


Survival of patients with ruptured abdominal aortic aneurysms (AAAs) more than doubles if they undergo endovascular aneurysm repair (EVAR) rather than open surgery, according to data presented January 22, 2013, at the 25th Annual International Symposium on Endovascular Therapy (ISET) in Miami Beach, FL.

Sherif Sultan, MB, MD, of University College Hospital Galway (Galway, Ireland), and colleagues conducted an observational, parallel-group comparison study of 106 patients who underwent AAA repair (n = 75 open surgery, n = 31 EVAR) at a single tertiary referral facility between 2002 and 2012.

Patients with ruptured AAA who underwent EVAR had higher survival rates—both aneurysm-related and all-cause—than those who underwent open surgery. Thirty-day aneurysm related survival was 70% with EVAR vs. 33% with open surgery (P = 0.0001), while overall mortality was 31% with EVAR vs. 68% with open surgery (95% CI 1.82-11.02; P < 0.001). One-year survival was also increased with EVAR vs. surgery (56% vs. 12.5%).

Most patients died from a coexisting health condition. Total aneurysm-related mortality was 12.5% at 1 week, 25% at 1 month, 37.5% at 6 months, 50% at 1 year, and 90% at 5 years.

Although there was no statistically significant difference in all-cause mortality between the 2 groups (P = 0.099), the absolute mortality reduction of 37% in patients receiving EVAR led the authors to conclude that the minimally invasive technique should be the standard of care.

Building the Evidence Base

“This study adds weight to the international evidence for endovascular management of ruptured AAA,” Dr. Sultan told TCTMD in an e-mail communication. “We now have an evidence base for our EVAR-first emergency protocols.”

However, Dr. Sultan cautioned that the data should be interpreted carefully. During the study period, his team gained experience with the technique by performing more than 500 elective EVAR procedures. “Our team are so adept and well practiced at performing EVAR in the elective setting that it translates nicely to the emergency setting,” he said. “The study findings can only be applied to similarly high-volume centers.”

While the results are not surprising, Benjamin W. Starnes, MD, of the University of Washington (Seattle, WA), commented to TCTMD in an e-mail communication, the long-term data are quite compelling and demonstrate the continued benefit of EVAR over open repair.

Size, Observational Nature Limit Study

Frank A. Lederle, MD, of the Veterans Affairs Medical Center (Minneapolis, MN), meanwhile, pointed out in an e-mail communication with TCTMD that the current study, due to its observational nature, “reflects patient selection for endovascular repair of those stable enough to reach an endovascular center, undergo imaging, and meet criteria for candidacy.”

The study includes far too few patients undergoing EVAR to draw any conclusions, said Dr. Lederle, adding that much larger observational studies have previously been reported.

Dr. Sultan explained that the center’s aggressive screening policy and early repair of AAAs measuring 5 cm in men and 4.7 cm in woman has resulted in a sharp decline in the number of patients with ruptured AAA. Even so, the currently reported 31 EVAR cases provide a sense of contemporary trends, he added.

According to Dr. Lederle, randomized controlled trials are the only way to learn if EVAR is better than open surgery for ruptured AAAs.

However, he reported, the only such trial published to date randomized just 32 patients and reported a 30-day mortality rate of 53% in each group (Hinchliffe RJ. Eur J Vasc Endovasc Surg. 2006;32:506-513). Additionally, the AJAX (Amsterdam Acute Aneurysm Trial), presented last year at the 34th Charing Cross International Symposium in London, randomized only 116 patients and did not confirm EVAR’s superiority to open surgery, Dr. Lederle noted.

He added that data from the 600-patient British randomized trial, IMPROVE (Immediate Management of the Patient with Ruptured Aneurysm: Open Versus Endovascular repair), will be available in November 2013.

A Vulnerable Population

Regardless of treatment mode, the long-term survival of patients with ruptured AAA is dismal due to comorbid conditions, said Dr. Sultan. “This indicates the fragility of the population we are dealing with and emphasizes that, in this context, the least-invasive treatment modality that provides cost-effective quality of life should be the treatment of choice,” he explained. “EVAR fits these criteria.”

The technique also allows for a shorter hospital stay, observed Dr. Sultan. “In some ways this [treatment] can be regarded as palliative care with minimal side-effects,” he said.

Dr. Starnes similarly commented that EVAR is less invasive and less physiologically burdensome to patients than surgery, especially in the setting of comorbidities. Compared to patients with asymptomatic AAA, these patients “are essentially on death's door, and every minute counts,” he said.

 


Source:
Sultan S. Paradigm shift in ruptured AAA (RAAA) management: Ten years experience in a tertiary referral centre of endovascular vs. open repair. Presented at: International Symposium on Endovascular Therapy; January 22, 2013; Miami Beach, FL.

 

 

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Endovascular Repair Ups Survival of Patients with Ruptured AAA

Survival of patients with ruptured abdominal aortic aneurysms (AAAs) more than doubles if they undergo endovascular aneurysm repair (EVAR) rather than open surgery, according to data presented January 22, 2013, at the 25th Annual International Symposium on Endovascular Therapy (ISET)
Disclosures
  • Drs. Sultan and Lederle report no relevant conflicts of interest.
  • Dr. Starnes reports holding intellectual property with Cook Incorporated but having received no financial remuneration.

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