SS18. Ruptured Abdominal Aortic Aneurysm: The Harborview Experience- Part 2

Article Outline

• Objectives
• Methods
• Results
• Conclusions
• Copyright

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Objectives 

Our institution treats between 30 and 50 patients per year with ruptured abdominal aortic aneurysm (rAAA) and our overall 30-day mortality between 2002 and 2007 averaged 60%. We sought to evaluate the effect on mortality of the implementation of an algorithm to manage these patients with a preference for endovascular aneurysm repair (EVAR) when feasible.

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Methods 

Patients presenting with rAAA between July 1, 2002 and June 30, 2007 served as retrospective controls. The treatment group consisted of patients presenting after July 1, 2007, who were treated with a structured protocol including early proximal control with an aortic occlusion balloon, permissive hypotension, and endovascular repair when possible. The primary outcome measure was 30-day mortality. Data were analyzed using Chi Square and Fisher's Exact Test where appropriate.

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Results 

The 30-day mortality for the 131 control patients was 60%. After implementation of the protocol, 50 patients with rAAA were managed. Eighteen (36%) underwent successful EVAR, and twenty-eight (46%) underwent open repair. Four patients (8%) received comfort care only. Three patients in the EVAR group (17%) and thirteen patients in the open group (46%) died during the follow up period for an overall 30-day mortality rate of 35% (p=0.006 vs 60% of controls). There was no difference in the incidence of hypotension on presentation (SBP<80mmHg) between control (65%) and treatment (61%) groups. In the treatment group, 28/46 (61%) presented with hypotension. The incidence of hypotension between open and EVAR patients did not differ in the treatment group. Average transfusion requirement for those undergoing EVAR was 1 unit (0-13) and for open repair, 8 units (0-19). The difference in transfusion requirement amongst survivors in each group was not different (p= 0.06).

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Conclusions 

An algorithm using early proximal aortic control with a balloon catheter, permissive hypotension, and endovascular repair when possible reduced rAAA mortality by 40% (absolute risk reduction of 25%). Using this approach in a large, urban hospital, the majority of patients presenting with rAAA survived. Further reduction in mortality is expected as improvement in endovascular techniques allows treatment of more patients with complex aortic anatomy.