| | A single-center experience in open and endovascular treatment of hemodynamically unstable and stable patients with ruptured abdominal aortic aneurysmsReceived 14 June 2006; accepted 26 August 2006.
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Refers to article:
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Popliteal Venous Aneurysm
Jeffrey P. Carpenter, Edward Y. Woo
Journal of Vascular Surgery
December 2006 (Vol. 44, Issue 6, Pages 1361-1362)
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ObjectiveTo retrospectively compare a single center’s immediate and mid-term outcomes of ruptured abdominal aortic aneurysm open and endovascular repair (EVAR) for two patient groups—hemodynamically stable and unstable patients—in the same time period. MethodsPatients presenting at our center with confirmed rupture of an abdominal aortic aneurysm between December 1999 and April 2006 were considered according to an intention-to-treat model with EVAR. Patients with symptomatic or acute (but not ruptured) AAAs were not included in this study. Thirty-three patients underwent EVAR, and 91 underwent open repair. Seventy-two patients (EVAR, 45%; open, 63%) were classified as hemodynamically unstable at arrival, and 52 were classified as stable (EVAR, 55%; open, 37%). Ninety-seven percent of EVAR procedures commenced under local anesthesia, and 100% of open repairs occurred with general anesthesia. Overall successful graft deployment, 30-day mortality, overall reintervention rate, and complications were the study primary end points. ResultsOverall successful graft deployment for EVAR was 91%; for open repair, it was 96%. Overall 30-day mortality for EVAR was 30% (unstable, 53%; stable, 11%), and the rate was 46% for open repair (unstable, 61%; stable, 21%). The EVAR postoperative reintervention rate (within 30 days) was 15% (unstable, 20%; stable, 11%), and for open repair it was 10% (unstable, 9%; stable, 15%). We recorded a 27% severe complication rate for EVAR patients (unstable, 40%; stable, 17%), and for patients treated with open repair, it was 33% (unstable, 35%; stable, 29%). Our overall EVAR eligibility rate was 52%, and our overall EVAR treatment rate was 27%. ConclusionsOur study’s overall results for EVAR remain encouraging when compared with those of conventional repair, but large randomized trials are required to confirm the efficacy of the procedure. The overall mortality rate for patients undergoing conventional repair of ruptured abdominal aortic aneurysms (rAAA) is up to 50%.1, 2, 3, 4, 5 Despite a documented gradual decrease in this mortality rate in a 50-year meta-analysis,1 it is generally accepted that there has been no consistent improvement in the number of operative deaths associated with rAAA in the last few decades.6 Conventional repair has inherent limitations, including general anesthesia and laparotomy.3, 7, 8, 9, 10, 11 The advantages of endovascular repair (EVAR) include the avoidance of both general anesthesia and laparotomy, thus improving the physiological stress of the procedure for the patient.12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22 EVAR itself also carries with it an inherent limitation: a delay of treatment due to necessary preoperative imaging. However, recent studies assessing the delay from patient arrival to death in nonsurgical groups conclude that it is safe to assess the majority of rAAA for EVAR.23, 24 Improvements in mortality and morbidity associated with EVAR with respect to conventional repair have been shown in some recent studies. However, these studies often include symptomatic, nonruptured aneurysms together with truly ruptured aneurysms, and most include a mix of stable and unstable patients.13, 17, 18, 20, 25, 26, 27, 28, 29, 30 We present our study as a comparison of the efficacy of EVAR compared with open repair for stable and unstable patients treated for rAAA in our center in the same study period. Methods  A total of 124 consecutive patients presented at our hospital during the study period (December 1999 to April 2006) with rAAA. Patients with acute or symptomatic but intact aneurysms shown at computed tomography (CT) were excluded. The exclusion criteria guidelines in our center for EVAR are based on anatomic parameters: proximal neck length less than 10 mm, proximal neck diameter greater than 32 mm, and external iliac artery diameter less than 7 mm and severe bilateral iliac artery disease. Thirty-three of the 124 patients were treated with EVAR. Thirty-one of the 91 surgically treated patients would have been anatomically suitable for EVAR but were treated with open repair at the beginning of our experience: 6 patients due to young age (initially considered a criteria of exclusion) and 25 patients due to unavailability of adequately trained staff and endovascular supplies. Our overall EVAR eligibility rate was 52% (64/124), and our overall EVAR treatment rate was 27% (33/124). The outcomes measured included immediate technical success (successful deployment of the graft with complete sealing of the aneurysm), conversion, immediate mortality (within 24 hours) and 30-day mortality, complications, reinterventions, mortality during patient follow-up, and intensive care unit (ICU) and hospital stay. We compared different rates in study outcomes between the groups by means of logistic regression analysis. The level of significance was P < .05. Stata for Windows (release 7.0) (StataCorp LP; College Station, Tex) statistical software package was used. The patient demographic data are displayed in Table I. These patients were categorized into two subgroups for comparative analysis according to their presentation at the hospital as being hemodynamically unstable (defined as unconscious and/or with a systolic blood pressure <80 mm Hg after fluid resuscitation) or hemodynamically stable (conscious and/or with a systolic blood pressure >80 mm Hg, with or without fluid resuscitation). Nineteen (58%) of the EVAR patients were preoperatively classified as unfit for surgical treatment because of advanced age and comorbidities. | | |  | Variable | EVAR | Open | |
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| Median age, y (range) | 81 (65-99) | 77 (53-92) | | | Sex (M/F) | 28/5 | 74/17 | | | Unstable | 15 | 57 | | | Stable | 18 | 34 | | | ASA class | | | | |  III | 49% | 52% | | | IV | 19% | 28% | | | V | 32% | 20% | | | Comorbidities | | | | | Diabetes | 18% | 11% | | | Smoker | 24% | 54% | | | Hypertension | 87% | 73% | | | Hyperlipidemia | 33% | 35% | | | Cardiac disease | 69% | 55% | | | Carotid disease | 3% | 5% | | | Renal disease | 6% | 15% | | | Respiratory disease | 69% | 30% | | | Previous laparotomy | 25% | 8% | | | Obesity | 40% | 30% | | | Patient unfit for AAA open repair | 19 (64%) | — | | | Patient unfit for general anesthesia | 13 (43%) | — | | | AAA maximum diameter (mm), median (range) | 70 (43-100) | 75 (60-100) | | | Neck diameter (mm), median (range) | 23 (20-30) | 27 (24-30) | | | Neck length (mm), median (range) | 26 (14-40) | 13 (0-28) | | | | |
All patients were assisted by a vascular surgeon and an anesthesiologist from their presentation at the emergency department through to the operating room. Permissive hypotension was practiced with prudent fluid resuscitation to keep systolic blood pressure around 80 mm Hg, to avoid a recommencement of or increase in bleeding. Eighty-four percent (EVAR, 88%; open, 83%) of patients were assessed by contrast-enhanced spiral CT 5-mm slices of the abdomen. Rupture with CT was defined as extravasation of blood surrounding the aneurysm, as evident by the scan. In 4 EVAR cases (12%) rupture was confirmed by intraoperative angiography and intravascular ultrasonography (IVUS) and in 16 open cases (18%) rupture was confirmed in the operating room. During the CT scanning, the operating room was prepared to further reduce delay. The patients’ anatomic suitability for emergency EVAR was also determined at CT. Five EVAR and 12 open cases were transferred from other hospitals with previously performed CT scans (delivered via a Dicon (Dicon; Kyonggi-do, Korea) intranet system for evaluation during patient transportation). The maximum time taken to execute the CT was between 5 and 7 minutes (total time delay of 15-20 minutes). The diameter and length of the aneurysms were evaluated directly by the vascular surgeon from the screen. Open repair was performed in the traditional fashion, as described in literature,31, 32, 33 with supraceliac clamping in 100% of the unstable patients and in 73% of the stable patients. All grafts used in the study were commercially available, supplied by Bard Inc (Murray Hill, New Jersey) and Boston Scientific (Watertown, Mass). Four of the 15 EVAR hemodynamically unstable patients followed a different course. These patients presented unconscious with severe hypotension (40-50 mm Hg) and were transferred directly to the operating room without CT. Intraoperative angiography and IVUS allowed confirmation of the rupture and evaluation of EVAR suitability. In these four patients, a prototype occlusion balloon, inserted from the contralateral femoral artery, was successfully used. This device, developed in collaboration with Edwards Lifesciences (Irvine, Calif), is similar to a calibrated catheter of 14F with a double channel (for balloon inflation and execution of intraoperative angiography). Once the balloon was inflated in the suprarenal aorta, an immediate increase in blood pressure was observed in all four patients. The endograft was then successfully positioned, and the occlusion balloon was deflated and withdrawn. All EVAR procedures were performed in a dedicated vascular operating room equipped with mobile C-arm (OEC 9800; GE Medical System, Salt Lake City, Utah), IVUS (Volcano s5; Volcano Corporation; Rancho Cordova, Calif), and ecoduplex scanner (Esaote AU 5; Socrate Medical Srl, Cesano Boscone, Milan, Italy). Our EVAR team includes two vascular surgeons (at least one endovascular expert), an anesthesiologist, an endovascular-trained operating room nurse, and a radiologic technician. Ninety-seven percent of the EVAR procedures commenced under local anesthesia (1% lidocaine) accompanied when required with intravenous sedation for pain relief and patient immobility. Arterial access was obtained through surgical exposure of both femoral arteries, except in one case (Powerlink bifurcated endograft; Endologix Inc, Irvine, Calif), for which it was obtained through the exposure of the right artery and percutaneous access through the left femoral artery. Intraoperative angiography was performed manually through a 7F or 8F 45-cm introducer sheath (Cordis; Cordis Corp; Hialeah, Fla) inserted from the femoral artery contralateral to the side chosen for the deployment of the endograft. A 9F 55-cm introducer sheath (Cordis; Cordis Corp; Hialeah, Fla) was used when IVUS was performed. With angiography, the exact positions of the renal arteries and the aortic bifurcation were determined and marked directly by the vascular surgeon on the C-arm screen. After the insertion of a super-stiff guidewire (Amplatz or Backup Meyer; Boston Scientific), the endograft was deployed. The aortouni-iliac device (AUI) coupled with a femorofemoral bypass was the preferred technique in rAAA (73%). Completion angiography confirmed adequate proximal and distal fixation and identified any endoleak. In the case of an AUI procedure, a contralateral plug was inserted, and the procedure was completed with a crossover femorofemoral bypass with a polytetrafluoroethylene graft. Most patients undergoing this procedure were converted to general anesthesia, but in seven patients the entire procedure was completed with local anesthesia. When required, postdilation was executed with a compliant balloon (Reliant; Medtronic, World Medical Manufacturing Corp, Sunrise, Fla). All of the endografts used in the study were commercially available: Talent (Medtronic Vascular, Santa Rosa, Calif), Excluder (W. L. Gore and Associates, Flagstaff, Ariz), Zenith (Cook, Bloomington, Ind), and Powerlink. The endografts were chosen according to the aneurysms’ anatomic characteristics. From the end of 2003, Cook has supplied our center with a specialized emergency kit of AUI Zenith endografts with proximal diameters of 24, 28, and 32 mm; a distal diameter of 12 mm; and a fixed 122-mm length. When necessary, the AUI graft can be lengthened with commercially available distal extensions. The EVAR follow-up scheme consisted of routine CT before discharge, at 3 and 12 months, and annually thereafter. Ecoduplex scanning was performed at 1 and 6 months and annually thereafter. Plain radiographs were performed before discharge, at 6 months, and annually thereafter. Open follow-up consisted of an ecoduplex scan at 1 month and the second and fifth years. Results Operative data are displayed in Table II. The procedural details illustrate less invasiveness by the EVAR procedure, with a reduced overall procedure duration and increased use of local anesthesia. The EVAR study results are presented in Table III. The four perioperative deaths were caused by intractable hypovolemic shock. Within the first 24 hours, three further deaths occurred: two from multiple organ failure and one from bowel infarction. A further patient died 12 days after the procedure from multiple organ failure. Both immediate and 30-day mortality were statistically significant between the two groups (P < .01). | | | | Variable | EVAR | Open | |
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| Product | | | | | Zenith | 13 (1 Bif, 12 AUI) | — | | | Talent | 12 (1 Bif, 11 AUI) | — | | | Powerlink | 3 (1 Bif, 1 AUI, 1 Tube) | — | | | Excluder | 4 (4 Bif) | — | | | Endologix | 1 (1 Tube) | — | | | Hemashield Gold | — | 77 (63 Tube, 14 Bif) | | | Bard | | 10 (9 Tube, 1 Bif) | | | Total | 33 | 87⁎ | | | Imaging Assessment | | | | | CT | | | | | Stable | 18 (100%) | 34 (100%) | | | Unstable | 11 (73%) | 41 (72%) | | | Intraoperative IVUS/angiography (without preoperative CT) | | | | | Stable | 0 | 0 | | | Unstable | 4 (27%) | 0 | | | Procedural time, min, median (range) | | | | | Duration skin to skin | 133 (60-510) | 178 (60-600) | | | AUI | 139 (60-510) | — | | | Bifurcated | 111 (60-180) | 247 (100-600) | | | Tube | 60 | 171 (60-360) | | | Anesthesia | | | | | Local | 11 (45%) | 0 | | | Local to general | 19 (52%) | 0 | | | Epidural | 1 (3%) | 0 | | | General | 0 | 91 (100%) | | | Volume of contrast agent, mL, median (range) | 201 (20-600) | — | | | | |
| ⁎ Four patients died during the intervention, before deployment of the graft. |
Three patients were immediately converted to open surgery. One conversion was due to the technical inability to successfully insert the AUI Talent endograft in a tortuous anatomy. A second conversion was performed because the device could not be attached to the short neck (AUI Talent). Furthermore, a proximal cuff could not be inserted to correct this error because of the bending of the endograft in the aneurysmal sac, thus impeding its passage. An aortobifemoral bypass was performed in both cases. Both of these patients died during surgery as a result of intractable hypovolemic shock. The final immediate conversion was also performed because an AUI Talent endograft could not be attached to the short, proximal neck; this resulted in a proximal endoleak that remained despite an attempted correction. A surgical aortoaortic interposition was then performed successfully. Of the 26 patients who survived successful endovascular treatment, 14 (54%) were transferred to the ICU. There were five (17%) incidents of postoperative systemic complications in three patients which were not associated with fatal outcomes. One patient developed abdominal compartment syndrome and underwent drainage of the hematoma by an extraperitoneal approach through a left iliac fossa cutdown. This situation was complicated further with acute renal failure necessitating dialysis, although the completion angiography showed patency of both renal arteries. One patient had a stroke, and another patient experienced respiratory insufficiency accompanied by gastrointestinal bleeding and was treated with medication only. We experienced five (17%) postoperative reinterventions. One patient developed a complete thrombosis of the AUI Talent endograft which was treated with an extra-anatomic axillobifemoral bypass. One patient developed a thrombosis of the crossover and a type III endoleak between the two segments of the AUI Talent endograft. This patient was treated with an additional segment of endograft, and the crossover was redone. A third patient developed a type I proximal endoleak (AUI Zenith), which was considered unsuitable for correction by the addition of a proximal cuff because of the shortness of the aneurysmal neck. Therefore, through a small abdominal incision, a Dacron band (DuPont, Wilmington, Del) was successfully placed around the proximal neck to reduce the diameter and obtain complete sealing. Another patient developed a type I distal endoleak (AUI Zenith) because of an incomplete sealing by the plug. A larger plug was inserted to correct the endoleak. The final patient had a type I proximal endoleak (AUI Talent), which was treated with a 25-mm balloon dilation of the proximal neck attachment, with a reduction, but not the complete exclusion, of the aneurysm. Given the modest entity of the endoleak, the hemodynamic stability, and the stability of the dimension of the hematoma at the postoperative CT, the patient was maintained under observation. Two secondary interventions were necessary during the follow-up period. At 1 year, a new type I distal endoleak was successfully treated with a distal extension. At 6 months, the patient who had previously been unsuccessfully treated with a balloon dilation in the postoperative period was converted after a further unsuccessful attempt at endovascular correction with a proximal cuff extension. Our overall incidence of endoleak was 17% (5/30), and 4 of the 5 occurrences were primary endoleaks. At a mean follow-up of 27.5 months (range, 30-1456 days), we have recorded five patient deaths. Two patients died 3 months after the intervention; one patient from the stable group experienced bowel infarction, and another patient from the unstable group died from a myocardial infarction. At 6 months, a third patient from the unstable group died from congestive heart failure. At the 1-year follow-up, two further deaths were recorded in the stable group (from a stroke and a bowel infarction). Table IV reports the results of the open repair, which compare to the results of other open repair studies.31, 32, 33 Table V compares the 30-day outcomes between the EVAR and open groups. The comparison of the mortality rates shows a lower rate for EVAR both in the stable and unstable groups (no statistical significance). Comparatively, the reintervention rate within 30 days was relatively higher for EVAR than for open repair (no statistical significance). | | | | Variable | Overall | Unstable | Stable | P value | |
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| No. patients in study | 91 | 57 | 34 | | | | Immediate mortality (within 24 h) | 31%(28/91) | 46%(26/57) | 6%(2/34) | <.01 | | | 30-d mortality | 46%(42/91) | 61%(35/57) | 21%(7/34) | <.01 | | | Postoperative reintervention (within 30 d) | 10%(9/91) | 9%(5/57) | 15%(4/34) | NS | | | Severe systemic complications | 33%(30/91) | 35%(20/57) | 29%(10/34) | NS | | | MOF (fatal) | 10 | 8 | 2 | — | | | Bowel infarction | 8(6fatal) | 5(4fatal) | 3(2fatal) | — | | | ACS | 1 | 1 | | — | | | Acute renal failure (dialysis) | 4 | 2 | 2 | — | | | Stroke | 1 | 1 | | — | | | Severe respiratory insufficiency | 5 | 2 | 3 | — | | | Gastrointestinal bleeding | 1 | 1 | | — | | | No. patients | 87 | 53 | 34 | NS | | | ICU stay, h, median (range) | 120(48-888) | 144(48-888) | 96(48-888) | NS | | | Hospital stay, d, median (range) | 14(2-42) | 12(2-37) | 10(2-42) | NS | | | | |
| | | | Variable | Unstable | Stable | |
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| EVAR | Open | P value | EVAR | Open | P value | |
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| No. patients | 45%(15/33) | 63%(57/91) | NS | 55%(18/33) | 37%(34/91) | NS | | | 30-d mortality | 53%(8/15) | 61%(35/57) | NS | 11%(2/18) | 21%(7/34) | NS | | | Postoperative reintervention (within 30 d) | 20%(3/15) | 9%(5/57) | NS | 11%(2/18) | 15%(4/34) | NS | | | Systemic complications | 40%(6/15) | 35%(20/57) | NS | 17%(3/18) | 29%(10/34) | NS | | | MOF (fatal) | 3 | 9 | — | 0 | 2 | — | | | Bowel infarction | 0 | 5(4fatal) | — | 1(fatal) | 3(2fatal) | — | | | ACS | 1 | 0 | — | 0 | 0 | — | | | Acute renal failure | 1 | 3 | — | 0 | 2 | — | | | Stroke | 1 | 1 | — | 0 | 0 | — | | | Severe respiratory insufficiency | 0 | 2 | — | 1 | 3 | — | | | Gastrointestinal bleeding | 0 | 1 | — | 1 | 0 | — | | | ICU stay, h, median (range) | 48(10-280) | 144(48-888) | NS | 24(4-48) | 96(48-888) | <.05 | | | Hospital stay, d (mean ± SD) | 15.1±6.6 | 14.1±9.4 | <.01 | 8.8±7.3 | 14.1±9.6 | NS | | | | |
As shown in the Figure, the cumulative survival probability for EVAR at 1 year is 49% (Kaplan-Meier curve). However, a significant difference can be observed between the two subgroups (P < .01). Discussion Both open repair and EVAR for rAAA in the literature have results that are difficult to interpret because often patients with symptomatic but not ruptured aneurysms are included, and the hemodynamic situations are not considered in relation to the outcome (Table VI). In our study, we included only patients with evidenced rupture. They were divided into two groups based on their hemodynamic condition in the period from arrival to intervention. This classification of the two patient groups was developed to discern whether there was a difference in terms of outcome. The definition of patients’ hemodynamic stability was difficult. The main criterion we chose, as is common in other studies, was the blood pressure at observation. We used a cutoff of 80 mm Hg. It is clear that the arterial pressure cannot alone be sufficient to give a true indication of the gravity of the individual patient’s condition, which often also depends on the amount of bleeding and the patient’s general condition before rupture of the aneurysm. The varying definitions render a comparison of the various studies difficult. Thus, a development of a consensus between experts is required to establish which patients will benefit from EVAR in comparison to open repair and whether, in some situations, abstention is indeed better than surgical or endovascular treatment.34 | | | | Study (location) | Period | No. Patients | Endograft type | Unstable patients | Mortality⁎ | |
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| Ohki, Veith, and associates (Montefiore)25, 26 | 1994-1999 | 20 | AUI, 17 homemade; Tube, 3 | 5(25%) | 2(10%) | | | Hinchliffe (Nottingham)14 | 1994-2000 | 20 | AUI | 4(20%) | 9(45%) | | | Scharrer-Pamler (Ulm)18 | 1995-2001 | 24 | AUI, 1; Bif, 19; Tube, 4 | 4(17%) | 5(21%) | | | Resch (Malmo)19 | 1997-2002 | 21 | AUI, 12; Bif, 9 | 5(24%) | 4(19%) | | | van Heerzeele (Ghent)21 | 1997-2002 | 9 | AUI, 5; Bif, 3; Tube, 1 | 5(56%) | 2(22%) | | | Hechelhammer (Zurich)27† | 1997-2003 | 37 | Bif, 35; Tube, 2 | 8(22%) | 4(10.9%) | | | Lachat (Zurich) 16† | 1998-2001 | 21 | Bif, 20; Tube, 1 | 3(14%) | 2(9.5%) | | | Gerassimidis (Thessaloniki)4 | 1998-2004 | 23 | AUI, 10; Bif, 14 | 9(36%) | 9(39%) | | | Yilmaz (Eindhoven)15‡ | 1999-2001 | 24(17ruptured) | AUI | 12(50%) | 4(24%) | | | Alsac (Créteil)28 | 2001-2004 | 17 | AUI, 8; Bif, 8; iliac ext, 1 | 0 | 4(23%) | | | Larzon (Sweden) 29 | 2001-2004 | 15 | Bif, 13; comb, 2 | 11(73%) | 2(13%) | | | Peppelenbosch (Belgium/Netherlands)30 | 2001-2004 | 35 | AUI, 32; Bif, 3 | 20(57%) | 8(23%) | | | Lee (Florida) 31§ | 2002-2004 | 13 | Bif | Unspecified | 3(23%) | | | Total/average | | 279 | AUI, 129 (46%); Bif, 137 (49%); Tube, 11 (4%); comb, 2 (1%) | 86(32%)∥ | 58(21%) | | | | |
| ⁎ Thirty-day mortality is given where possible. †Same partial patient cohort; the Hechelhammer series was a more recent and larger study. ‡The Eindhoven study also contained symptomatic and acute patients without rupture. §Unspecified percentage of hemodynamically unstable patients; no patients were excluded on the basis of hemodynamic instability. ∥The Florida study was not included, in which unstable patients were unspecified. |
A crucial point to consider when treating with EVAR is the time delay linked to the necessary CT scan, particularly in hemodynamically unstable patients. In our center, the time delay for a CT scan has been reduced to approximately 15 to 20 minutes, in line with other specialized centers.16, 29, 35 In reality, the survival of patients arriving alive in the hospital with rAAA is longer than one usually believes. Lloyd et al23 reported a survival longer than 2 hours in 87.5% of untreated rAAA patients and a median time from the beginning of symptoms to death of more than 16 hours. Furthermore, Walker et al36 reported a mean time interval between admission and death of 8 hours. In our experience, four EVAR patients who presented in a state of shock (with blood pressure <50 mm Hg) underwent a simple ecoduplex scan and were then transported immediately to the operating room without CT. However, except for extreme and selected cases, the CT scan remains our first-choice imaging assessment for rAAA because it offers a sure diagnosis of rupture, showing the periaortic hematoma; it supplies vital information about the arterial accesses and the aneurysmatic morphology and, hence, permits rapid evaluation of endovascular feasibility. In these same four EVAR patients, we used a prototype occlusion balloon, which proved extremely useful. In general, the aortic occlusion balloon represents a theoretical advantage because it mimics surgical clamping and immediately slows the hemorrhage. However, dedicated occlusion balloons are not available on the market, and the use of nondedicated balloons is problematic, primarily because of balloon instability and diameter, the flexibility of the catheters, and problems linked to executing angiography appropriately.37 For all of these issues, we believe that, today, the rapid deployment of the endograft is preferable,4, 14, 27 with the exception of gravely unstable patients.37 In EVAR treatment, we developed a preference for the AUI endograft (used in 73% of cases) given its simple and rapid deployment and greater anatomic adaptability. Our preference is not supported on the whole by other studies, which collectively have a mean use of AUI of 46.2% (Table VI). EVAR has a higher reintervention rate than open repair (Table V). This could be attributed to the great dimensions and difficult anatomies of these patients selected for EVAR, especially in terms of tortuosity and shortness of the aneurysmatic neck, and the necessary rapidity of the procedure. The principal studies of EVAR for rAAA (Table VI) report a mean mortality rate of 21% (varying from 9.5% to 45%), which is significantly lower than the historical mortality rates associated with surgery.31, 32, 33 However, there are very few published experiences of EVAR for rAAA, and these also have limited patient numbers (few studies have >25 patients). Furthermore, the mean percentage of patients treated who are hemodynamically unstable and, therefore, at higher risk is infrequently specified, but our literature review shows it to be 32%.4, 14, 15, 16, 18, 19, 21, 25, 26, 27, 28, 29, 30 Although the combined mortality rates of 30% for EVAR and 46% for the surgically treated group (Table V) are not statistically significant, these results encourage us to continue our intention to treat with EVAR at our institution. However, our limited experience is not evidence that EVAR should be considered the first-choice treatment for rAAA. Whether EVAR should be considered a preferable option for stable or unstable patients remains unknown. Our experience shows a greater advantage for EVAR in stable patients in terms of mortality, morbidity, and ICU stay, and this is quite surprising given that it would have been logical to hypothesize that the patients in the most critical condition (unstable) would be those who would benefit most from a less invasive approach. An explanation of the similar mortality for EVAR and open treatment in the unstable group could be that the grave condition of the patient at presentation is the determining factor for survival, rather than the type of intervention chosen. The relatively higher mortality rate for the stable open group when compared with the stable EVAR group could be explained by the fact that the high invasiveness of the surgical treatment could precipitate the patients from a stable condition to an unstable one, thereby worsening their chances of survival. The improvements of the diagnostic/therapeutic course and of the availability of materials seem to have positively conditioned the results, but further improvements seem possible, such as dedicated kits that render the procedure more rapid and simple. Certainly, randomized trials are mandatory to establish the real efficacy of EVAR for rAAA. Author contributions Conception and design: GC, RS, SG Analysis and interpretation: GC, RS, SG, AVC Data collection: SG, GS Writing the article: GC, RS, SG Critical revision of the article: GC, RS, SG, GS, AVC Final approval of the article: GC, RS, SG Statistical analysis: SG, AVC Overall responsibility: GC See Invited Commentary, page 1361 The authors thank Johanna Chester, who helped coordinate the data collection, analysis, and writing of the article. References 1. 1Bown MJ, Sutton AJ, Bell PR, Sayers RD. A meta-analysis of 50 years of ruptured abdominal aortic aneurysm repair. Br J Surg. 2002;89:714–730. MEDLINE |
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Department of Vascular Surgery, Policlinico Hospital of Modena and University of Studies of Modena and Reggio Emilia, Modena, Italy.  Reprint requests: Gioacchino Coppi, MD, Department of Surgery, Operative Unit of Vascular Surgery, Policlinico of Modena, via del Pozzo, 71, 41100 Modena, Italy.
Competition of interest: none. PII: S0741-5214(06)01608-9 doi:10.1016/j.jvs.2006.08.070 © 2006 The Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved. | |
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