title: Endovascular repair of ruptured abdominal aortic aneurysm: A strategy in need of definitive evidence.
abstract: BACKGROUND
  Endovascular strategies have been increasingly used to manage patients with ruptured abdominal aortic aneurysm (AAA) in an attempt to improve patient survival. We analyzed the evidence to support such an approach.
  
  
  METHODS
  We performed a systematic literature review of endovascular aneurysm repair (EVAR) of ruptured AAA from 1994 to 2009. The literature analyzed included systematic reviews and population-based studies of ruptured AAA.
  
  
  RESULTS
  Seven systematic reviews were identified, all demonstrating from published data that patients with EVAR of ruptured AAA had significantly reduced mortality compared with controls. Six recently published population-based studies from the United States demonstrated low mortality rates associated with EVAR; however, only a small proportion of ruptured AAAs were treated by EVAR. Systematic reviews and population-based studies both raised concerns about patient selection and publication bias. Two randomized trials are in progress, and one is due to commence 2009.
  
  
  CONCLUSIONS
  The outcome of EVAR in a nonselected patient population remains unknown. One or more definitive randomized trials could provide the level I evidence to resolve these issues.
authors.affiliation: St. George's Vascular Institute, London, United Kingdom.
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Hinchliffe
authors.forename: Janet T
authors.initials: JT
authors.lastname: Powell
authors.forename: Nicholas J
authors.initials: NJ
authors.lastname: Cheshire
authors.forename: Matthew M
authors.initials: MM
authors.lastname: Thompson