title: Management of ruptured abdominal aortic aneurysm in the endovascular era.
abstract: OBJECTIVE
  Our institution treats about 30 patients per year with ruptured abdominal aortic aneurysms (rAAA). Between 2002 and 2007, our 30-day mortality averaged 58%. In July 2007, we implemented an algorithm to promote endovascular aneurysm repair (EVAR) when feasible. This report describes the outcome with this approach.
  
  
  METHODS
  Data on patients presenting with rAAA between July 1, 2002, and June 30, 2007, were reviewed and used for comparison to prospectively collected data. Data on patients presenting between July 1, 2007, and April 30, 2009, were collected on all patients after implementation of a structured protocol. The primary outcome measure was 30-day mortality. Data were analyzed using logistic regression. Kaplan-Meier survival curves and a log-rank test were performed to compare survival times for three groups (pre-protocol, post-protocol with open surgery, and post-protocol with EVAR).
  
  
  RESULTS
  During the study period, 187 patients with rAAA presented to our institution. Before implementation of the algorithm, 131 patients with rAAA presented and 128 were treated. The 30-day mortality rate was 57.8%. After implementation of the protocol, 56 patients with rAAA were managed. Twenty-seven patients (48%) underwent successful EVAR, and 24 patients (43%) underwent open repair. Five patients (9%) underwent comfort care only. In the post-protocol period, 5 patients in the EVAR group (18.5%) and 13 patients in the open group (54.2%) died during the follow-up period for an overall 30-day mortality rate of 35.3% (P = .008 vs 57.8% pre-protocol). After implementation of a structured protocol for managing rAAA, there was a relative risk reduction in 30-day mortality of 35% compared to the time before implementation of the protocol (95% confidence interval [CI], 14%-51%) corresponding to an absolute risk reduction of 22.5% (95% CI, 6.8%-38.2%) and an odds ratio of 0.40 (95% CI, 0.20-0.78; P = .007). After adjusting for key factors predicting mortality, the odds ratio is 0.25 (95% CI, 0.10-0.57; P = .001).
  
  
  CONCLUSIONS
  Use of an algorithm favoring endovascular repair resulted in a highly significant reduction in rAAA mortality in our urban hospital. Thirty-day mortality for open repair was no different between pre- and post-protocol eras. With modern techniques of resuscitation and surgical management, a majority of patients presenting with rAAA can survive.
authors.affiliation: Division of Vascular Surgery, University of Washington, Seattle, Wash 98104, USA. starnes@u.washington.edu
authors.forename: Benjamin W
authors.initials: BW
authors.lastname: Starnes
authors.forename: Elina
authors.initials: E
authors.lastname: Quiroga
authors.forename: Carolyn
authors.initials: C
authors.lastname: Hutter
authors.forename: Nam T
authors.initials: NT
authors.lastname: Tran
authors.forename: Thomas
authors.initials: T
authors.lastname: Hatsukami
authors.forename: Mark
authors.initials: M
authors.lastname: Meissner
authors.forename: Gale
authors.initials: G
authors.lastname: Tang
authors.forename: Ted
authors.initials: T
authors.lastname: Kohler
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D017544:Aortic Aneurysm, Abdominal / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D001019:Aortic Rupture / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D001803:Blood Transfusion; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000401:mortality; D002985:Clinical Protocols; D015897:Comorbidity; D003161:Compartment Syndromes / Q000209:etiology; D005260:Female; D006439:Hemodynamics; D017052:Hospital Mortality; D006786:Hospitals, Urban; D006801:Humans; D053208:Kaplan-Meier Estimate; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D018579:Patient Selection; D015397:Program Evaluation; D011446:Prospective Studies; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome