A comparison of open surgery versus endovascular repair of unstable ruptured abdominal aortic aneurysms

Prateek K. Gupta, Bala Ramanan, Travis L. Engelbert, Girma Tefera, John R. Hoch, K. Craig Kent

Research output: Contribution to journalArticle

39 Citations (Scopus)

Abstract

Objective: Two randomized trials to date have compared open surgery (OS) and endovascular (EVAR) repair for ruptured abdominal aortic aneurysm (rAAA); however, neither addressed optimal management of unstable patients. Single-center reports have produced conflicting data regarding the superiority of one vs the other, with the lack of statistical power due to low patient numbers. Furthermore, previous studies have not delineated between the outcomes of stable patients with a contained rupture vs those patients with instability. Our objective was to compare 30-day outcomes in patients undergoing OS vs EVAR for all rAAAs, focusing specifically on patients with instability. Methods: Patients who underwent repair of rAAA were identified from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database (2005 to 2010). Unstable patients with rupture were identified as those who were American Society of Anesthesiologists Physical Status Classification 4 or 5 requiring emergency repair with at least one of the following: preoperative shock, preoperative transfusion of <4 units, preoperative intubation, or preoperative coma or impaired sensorium. Univariable and multivariable logistic regression analyses were performed. Results: Of the 1447 patients with rAAA, 65.5% underwent OS and 34.5% EVAR. Forty-five percent were unstable, and for these patients, OS was performed in 71.3% and EVAR in 28.7%. The 30-day mortality rate was 47.9% (OS, 52.8%; EVAR, 35.6%; P <.0001) for unstable rAAAs and was 22.4% for stable rAAAs (OS, 26.3%; EVAR, 16.4%; P =.001). Amongst patients with unstable rAAA, 26% had a myocardial infarction or cardiac arrest ≥30 days (OS, 29.0%; EVAR, 19.1%; P =.006), and 17% needed postoperative dialysis (OS, 18.7%; EVAR, 12.8%; P =.04). Amongst patients with stable rAAA, 13.6% had a myocardial infarction or cardiac arrest ≥30 days (OS, 14.9%; EVAR, 11.6%; P =.20), and 11.5% needed postoperative dialysis (OS, 13.3%; EVAR, 8.7%; P =.047). Multivariable analyses showed OS was a predictor of 30-day mortality for unstable rAAA (odds ratio, 1.74; 95% confidence interval, 1.16-2.62) and stable rAAA (odds ratio, 1.64; 95% confidence interval, 1.10-2.43). Conclusions: Approximately one-third of patients treated for rAAA undergo EVAR in NSQIP participating hospitals. Not surprisingly, unstable patients have less favorable outcomes. In both stable and unstable rAAA patients, EVAR is associated with a diminished 30-day mortality and morbidity.

Original languageEnglish (US)
Pages (from-to)1439-1445
Number of pages7
JournalJournal of Vascular Surgery
Volume60
Issue number6
DOIs
StatePublished - Jan 1 2014

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Aortic Rupture
Abdominal Aortic Aneurysm
Quality Improvement
Heart Arrest
Ambulatory Surgical Procedures
Mortality
Rupture
Dialysis
Odds Ratio
Myocardial Infarction
Confidence Intervals
Coma
Intubation

ASJC Scopus subject areas

  • Surgery
  • Cardiology and Cardiovascular Medicine

Cite this

A comparison of open surgery versus endovascular repair of unstable ruptured abdominal aortic aneurysms. / Gupta, Prateek K.; Ramanan, Bala; Engelbert, Travis L.; Tefera, Girma; Hoch, John R.; Kent, K. Craig.

In: Journal of Vascular Surgery, Vol. 60, No. 6, 01.01.2014, p. 1439-1445.

Research output: Contribution to journalArticle

Gupta, Prateek K. ; Ramanan, Bala ; Engelbert, Travis L. ; Tefera, Girma ; Hoch, John R. ; Kent, K. Craig. / A comparison of open surgery versus endovascular repair of unstable ruptured abdominal aortic aneurysms. In: Journal of Vascular Surgery. 2014 ; Vol. 60, No. 6. pp. 1439-1445.
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abstract = "Objective: Two randomized trials to date have compared open surgery (OS) and endovascular (EVAR) repair for ruptured abdominal aortic aneurysm (rAAA); however, neither addressed optimal management of unstable patients. Single-center reports have produced conflicting data regarding the superiority of one vs the other, with the lack of statistical power due to low patient numbers. Furthermore, previous studies have not delineated between the outcomes of stable patients with a contained rupture vs those patients with instability. Our objective was to compare 30-day outcomes in patients undergoing OS vs EVAR for all rAAAs, focusing specifically on patients with instability. Methods: Patients who underwent repair of rAAA were identified from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database (2005 to 2010). Unstable patients with rupture were identified as those who were American Society of Anesthesiologists Physical Status Classification 4 or 5 requiring emergency repair with at least one of the following: preoperative shock, preoperative transfusion of <4 units, preoperative intubation, or preoperative coma or impaired sensorium. Univariable and multivariable logistic regression analyses were performed. Results: Of the 1447 patients with rAAA, 65.5{\%} underwent OS and 34.5{\%} EVAR. Forty-five percent were unstable, and for these patients, OS was performed in 71.3{\%} and EVAR in 28.7{\%}. The 30-day mortality rate was 47.9{\%} (OS, 52.8{\%}; EVAR, 35.6{\%}; P <.0001) for unstable rAAAs and was 22.4{\%} for stable rAAAs (OS, 26.3{\%}; EVAR, 16.4{\%}; P =.001). Amongst patients with unstable rAAA, 26{\%} had a myocardial infarction or cardiac arrest ≥30 days (OS, 29.0{\%}; EVAR, 19.1{\%}; P =.006), and 17{\%} needed postoperative dialysis (OS, 18.7{\%}; EVAR, 12.8{\%}; P =.04). Amongst patients with stable rAAA, 13.6{\%} had a myocardial infarction or cardiac arrest ≥30 days (OS, 14.9{\%}; EVAR, 11.6{\%}; P =.20), and 11.5{\%} needed postoperative dialysis (OS, 13.3{\%}; EVAR, 8.7{\%}; P =.047). Multivariable analyses showed OS was a predictor of 30-day mortality for unstable rAAA (odds ratio, 1.74; 95{\%} confidence interval, 1.16-2.62) and stable rAAA (odds ratio, 1.64; 95{\%} confidence interval, 1.10-2.43). Conclusions: Approximately one-third of patients treated for rAAA undergo EVAR in NSQIP participating hospitals. Not surprisingly, unstable patients have less favorable outcomes. In both stable and unstable rAAA patients, EVAR is associated with a diminished 30-day mortality and morbidity.",
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T1 - A comparison of open surgery versus endovascular repair of unstable ruptured abdominal aortic aneurysms

AU - Gupta, Prateek K.

AU - Ramanan, Bala

AU - Engelbert, Travis L.

AU - Tefera, Girma

AU - Hoch, John R.

AU - Kent, K. Craig

PY - 2014/1/1

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N2 - Objective: Two randomized trials to date have compared open surgery (OS) and endovascular (EVAR) repair for ruptured abdominal aortic aneurysm (rAAA); however, neither addressed optimal management of unstable patients. Single-center reports have produced conflicting data regarding the superiority of one vs the other, with the lack of statistical power due to low patient numbers. Furthermore, previous studies have not delineated between the outcomes of stable patients with a contained rupture vs those patients with instability. Our objective was to compare 30-day outcomes in patients undergoing OS vs EVAR for all rAAAs, focusing specifically on patients with instability. Methods: Patients who underwent repair of rAAA were identified from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database (2005 to 2010). Unstable patients with rupture were identified as those who were American Society of Anesthesiologists Physical Status Classification 4 or 5 requiring emergency repair with at least one of the following: preoperative shock, preoperative transfusion of <4 units, preoperative intubation, or preoperative coma or impaired sensorium. Univariable and multivariable logistic regression analyses were performed. Results: Of the 1447 patients with rAAA, 65.5% underwent OS and 34.5% EVAR. Forty-five percent were unstable, and for these patients, OS was performed in 71.3% and EVAR in 28.7%. The 30-day mortality rate was 47.9% (OS, 52.8%; EVAR, 35.6%; P <.0001) for unstable rAAAs and was 22.4% for stable rAAAs (OS, 26.3%; EVAR, 16.4%; P =.001). Amongst patients with unstable rAAA, 26% had a myocardial infarction or cardiac arrest ≥30 days (OS, 29.0%; EVAR, 19.1%; P =.006), and 17% needed postoperative dialysis (OS, 18.7%; EVAR, 12.8%; P =.04). Amongst patients with stable rAAA, 13.6% had a myocardial infarction or cardiac arrest ≥30 days (OS, 14.9%; EVAR, 11.6%; P =.20), and 11.5% needed postoperative dialysis (OS, 13.3%; EVAR, 8.7%; P =.047). Multivariable analyses showed OS was a predictor of 30-day mortality for unstable rAAA (odds ratio, 1.74; 95% confidence interval, 1.16-2.62) and stable rAAA (odds ratio, 1.64; 95% confidence interval, 1.10-2.43). Conclusions: Approximately one-third of patients treated for rAAA undergo EVAR in NSQIP participating hospitals. Not surprisingly, unstable patients have less favorable outcomes. In both stable and unstable rAAA patients, EVAR is associated with a diminished 30-day mortality and morbidity.

AB - Objective: Two randomized trials to date have compared open surgery (OS) and endovascular (EVAR) repair for ruptured abdominal aortic aneurysm (rAAA); however, neither addressed optimal management of unstable patients. Single-center reports have produced conflicting data regarding the superiority of one vs the other, with the lack of statistical power due to low patient numbers. Furthermore, previous studies have not delineated between the outcomes of stable patients with a contained rupture vs those patients with instability. Our objective was to compare 30-day outcomes in patients undergoing OS vs EVAR for all rAAAs, focusing specifically on patients with instability. Methods: Patients who underwent repair of rAAA were identified from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database (2005 to 2010). Unstable patients with rupture were identified as those who were American Society of Anesthesiologists Physical Status Classification 4 or 5 requiring emergency repair with at least one of the following: preoperative shock, preoperative transfusion of <4 units, preoperative intubation, or preoperative coma or impaired sensorium. Univariable and multivariable logistic regression analyses were performed. Results: Of the 1447 patients with rAAA, 65.5% underwent OS and 34.5% EVAR. Forty-five percent were unstable, and for these patients, OS was performed in 71.3% and EVAR in 28.7%. The 30-day mortality rate was 47.9% (OS, 52.8%; EVAR, 35.6%; P <.0001) for unstable rAAAs and was 22.4% for stable rAAAs (OS, 26.3%; EVAR, 16.4%; P =.001). Amongst patients with unstable rAAA, 26% had a myocardial infarction or cardiac arrest ≥30 days (OS, 29.0%; EVAR, 19.1%; P =.006), and 17% needed postoperative dialysis (OS, 18.7%; EVAR, 12.8%; P =.04). Amongst patients with stable rAAA, 13.6% had a myocardial infarction or cardiac arrest ≥30 days (OS, 14.9%; EVAR, 11.6%; P =.20), and 11.5% needed postoperative dialysis (OS, 13.3%; EVAR, 8.7%; P =.047). Multivariable analyses showed OS was a predictor of 30-day mortality for unstable rAAA (odds ratio, 1.74; 95% confidence interval, 1.16-2.62) and stable rAAA (odds ratio, 1.64; 95% confidence interval, 1.10-2.43). Conclusions: Approximately one-third of patients treated for rAAA undergo EVAR in NSQIP participating hospitals. Not surprisingly, unstable patients have less favorable outcomes. In both stable and unstable rAAA patients, EVAR is associated with a diminished 30-day mortality and morbidity.

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