eComment: Endovascular repair of ruptured abdominal aortic ...

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Authors: Kosmas I. Paraskevas, Department of Vascular Surgery, Red. Cross Hospital, 24 Al. ... Tsiantoula, Dimitri P. Mikhailidis, Athanasios D. Giannoukas.

ARTICLE IN PRESS J. Foster et al. / Interactive CardioVascular and Thoracic Surgery 10 (2010) 611–619

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w1x Foster J, Ghosh J, Baguneid M. In patients with ruptured abdominal aortic aneurysm does endovascular repair improve 30-day mortality? Interact CardioVasc Thorac Surg 2010;10:611–619. w2x Kapma MR, Verhoeven EL, Tielliu IF, Zeebregts CJ, Prins TR, Van der Heij B, Van den Dungen JJ. Endovascular treatment of acute abdominal aortic aneurysm with a bifurcated stentgraft. Eur J Vasc Endovasc Surg 2005;29:510–515. w3x Sadat U, Boyle JR, Walsh SR, Tang T, Varty K, Hayes PD. Endovascular vs open repair of acute abdominal aortic aneurysms – a systematic review and meta-analysis. J Vasc Surg 2008;48:227–236. w4x Bengtsson H, Bergqvist D. Ruptured abdominal aortic aneurysm: a population-based study. J Vasc Surg 1993;18:74–80. w5x Reichart M, Geelkerken RH, Huisman AB, van Det RJ, de Smit P, Volker EP. Ruptured abdominal aortic aneurysm: endovascular repair is feasible in 40% of patients. Eur J Vasc Endovasc Surg 2003;26:479–486.

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Authors: Kosmas I. Paraskevas, Department of Vascular Surgery, Red Cross Hospital, 24 Al. Papagou Street, 14122 Athens, Greece; Paraskevi Tsiantoula, Dimitri P. Mikhailidis, Athanasios D. Giannoukas doi:10.1510/icvts.2009.228866A Foster et al. w1x support that for ruptured abdominal aortic aneurysms (AAAs), endovascular AAA repair (EVAR) is achievable and appears to be associated with favorable mortality over open AAA repair with appropriate case selection.

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eComment: Endovascular repair of ruptured abdominal aortic aneurysms: identifying issues which may be difficult to achieve

Several earlier studies have demonstrated that EVAR is associated with reduced mortality rates for the management of ruptured AAAs compared with open AAA repair w2, 3x. A recent meta-analysis showed that compared with open AAA repair, EVAR is associated with a significant 38% reduction in 30-day mortality wpooled odds ratio 0.624; 95% confidence interval (CI), 0.518–0.752; P-0.0001x, a shorter intensive care unit (pooled effect size estimate –0.70 days; 95% CI, –1.05 to –0.35 days; P-0.0001) and hospital stay (pooled effect size estimate –0.33 days; 95% CI, –0.50 to –0.16 days; Ps0.0001), as well as a significant reduction in blood loss (pooled effect size estimate –1.88 l; 95% CI, –2.49 to –1.27 l; P-0.0001) and procedure time (pooled effect size estimate –0.65 h; 95% CI, –0.95 to –0.36 h; Ps0.0001) for the management of acute (ruptured and symptomatic intact) AAAs w3x. Although it is probably a fact that EVAR should be preferred over open AAA repair for the management of ruptured AAAs, there are some practical difficulties. Firstly, not all hospitals may have the appropriate personnel for the performance of EVAR on a 24-h/day basis; the associated cost implications are substantial (if not prohibitive). In addition, each hospital should maintain an appropriate stock of materials required for emergency EVAR (e.g. catheters, stent grafts). Such an action also has considerable cost implications. This could be compensated for by having dedicated regional centers although this creates other problems, such as time required to reach the center and whether a specialist team could potentially handle more than one case within a certain time interval. On the other hand, as the authors mention w1x, not all patients presenting with ruptured AAAs will be hemodynamically stable to undergo a detailed CT-scan examination for the evaluation of the appropriateness of the AAA for EVAR. A large percentage of these patients reach the hospital in a state of hemodynamic instability w4x. For these patients, the option of EVAR is not an issue. Finally, a considerable percentage of ruptured AAAs will not be anatomically suitable for EVAR w2, 5x. EVAR should indeed be the first option in patients with ruptured (but hemodynamically stable) AAAs. However, it may be incorrect to support that offering EVAR as the primary treatment option for ruptured AAAs is achievable. The considerable costs associated with EVAR may render such a strategy incompatible with reality.

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w15x Wibmer A, Schoder M, Wolff KS, Prusa AM, Sahal M, Lammer J, Huk I, Polterauer P, Kretschmer G, Teufelsbauer H. Improved survival after abdominal aortic aneurysm rupture by offering both open and endovascular repair. Arch Surg 2008;143:544–549. w16x Lesperance K, Andersen C, Singh N, Starnes B, Martin MJ. Expanding use of emergency endovascular repair for ruptured abdominal aortic aneurysms: disparities in outcomes from a nationwide perspective. J Vasc Surg 2008;47:1165–1170. w17x Kubin K, Sodeck GH, Teufelsbauer H, Nowatschka B, Kretschmer G, Lammer J, Schoder M. Endovascular therapy of ruptured abdominal aortic aneurysm: mid- and long-term results. Cardiovasc Intervent Radiol 2008;31:496–503. w18x Lee RW, Rhodes JM, Singh MJ, Davies MG, Wolford HY, Diachun C, Norton R, Illig KA. Is there a selection bias in applying endovascular aneurysm repair for rupture? Ann Vasc Surg 2008;22:215–220. w19x Najjar SF, Mueller KH, Ujiki MB, Morasch MD, Matsumura JS, Eskandari MK. Percutaneous endovascular repair of ruptured abdominal aortic aneurysms. Arch Surg 2007;142:1049–1052. w20x Anain PM, Anain JM Sr, Tiso M, Nader ND, Dosluoglu HH. Early and midterm results of ruptured abdominal aortic aneurysms in the endovascular era in a community hospital. J Vasc Surg 2007;46:898–905. w21x Visser JJ, van Sambeek MR, Hamza TH, Hunink MG, Bosch JL. Ruptured abdominal aortic aneurysms: endovascular repair versus open surgery– systematic review. Radiology 2007;245:122–129. w22x Hinchliffe RJ, Braithwaite BD. Ruptured abdominal aortic aneurysm: endovascular repair does not confer any long-term survival advantage over open repair. Vascular 2007;15:191–196. w23x Sharif MA, Lee B, Makar RR, Loan W, Soong CV. Role of the Hardman index in predicting mortality for open and endovascular repair of ruptured abdominal aortic aneurysm. J Endovasc Ther 2007;14:528– 535. w24x Ockert S, Schumacher H, Bo ¨ckler D, Megges I, Allenberg JR. Early and mid-term results after open and endovascular repair of ruptured abdominal aortic aneurysms in a comparative analysis. J Endovasc Ther 2007;14:324–332. w25x Hinchliffe RJ, Bruijstens L, MacSweeney STR, Braithwaite BD. A randomised trial of endovascular and open surgery for ruptured abdominal aortic aneurysm: results of a pilot study and lessons learned for future studies. Eur J Vasc Endovasc Surg 2006;32:506–513.

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