title: Prior endovascular abdominal aortic aneurysm repair provides no survival benefits when the aneurysm ruptures.
abstract: OBJECTIVE
  It has been proposed that prior endovascular abdominal aortic aneurysm (AAA) repair (EVAR) confers protective effects in the setting of ruptured AAA (rAAA). This study was conducted to compare outcomes of rAAA repairs in patients with and without prior EVAR.
  
  
  METHODS
  A retrospective review identified 18 patients with (group 1) and 233 patients without (group 2) antecedent EVAR who presented with rAAA from January 2001 to December 2008. Patient characteristics and perioperative variables were noted and the outcomes were compared. Multiple logistic regression was used to identify factors contributing to morbidity and mortality and Kaplan-Meier analyses to estimate late survival rates.
  
  
  RESULTS
  Baseline characteristics were similar between groups. Mean age was 78 years in group 1 and 74.8 years in group 2 (P=.17). Men comprised 83.3% of patients in group 1 and 77.3% in group 2 (P=.77). Hemodynamic instability at rAAA was noted with similar frequency between groups, 55.6% vs 52.6%, respectively (P=.99). Mean time from EVAR to rAAA was 4.0 years and from last follow-up computed tomography (CT) 1.2 years. The devices involved were Ancure (Guidant, Menlo Park, Calif) (9), AneuRx (Medtronic, Minneapolis, Minn) (5), Zenith (Cook Medical Inc, Bloomington, Ind) (3), and Excluder (W.L Gore, Flagstaff, Ariz) (1). Mean preoperative AAA size was 6.4 cm in group 1. All but 1 patient had an endoleak at the time of rupture. Of 14 patients with CT follow-up, only 3 patients had a known increase in size (≥5 mm) and only 3 were known to have an endoleak. Fifteen patients were treated by a single intervention, whereas 3 patients underwent multiple procedures. In group 2, open repair was performed in 218 patients and EVAR in 15. Morbidity (66.7% vs 56.7%) and in-hospital mortality (38.9% vs 36.9%) were nearly identical between groups. One-year survival rates (27.8% vs 48.2%; P=.15) were also similar. The mortality rates for EVAR for primary rAAA was 20% as compared to 38.1% for open repair for rAAAs (P=.27).
  
  
  CONCLUSIONS
  rAAA remains a lethal problem in patients with and without prior EVAR alike. An existing endograft provides neither acute nor 1-year survival benefits after rAAA repairs. Prediction of patients at risk for rupture post-EVAR is difficult, as only a minority of patients had a known prior endoleak or sac enlargement.
authors.affiliation: Department of Surgery, Division of Vascular Surgery, University of Pittsburgh School of Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA. chojs@upmc.edu
authors.forename: Jae-Sung
authors.initials: JS
authors.lastname: Cho
authors.forename: Taeyoung
authors.initials: T
authors.lastname: Park
authors.forename: Jang Yong
authors.initials: JY
authors.lastname: Kim
authors.forename: Rabih A
authors.initials: RA
authors.lastname: Chaer
authors.forename: Robert Y
authors.initials: RY
authors.lastname: Rhee
authors.forename: Michel S
authors.initials: MS
authors.lastname: Makaroun
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D017544:Aortic Aneurysm, Abdominal / Q000150:complications / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D001019:Aortic Rupture / Q000000981:diagnostic imaging / Q000209:etiology / Q000401:mortality* / Q000601:surgery*; D001027:Aortography / Q000379:methods; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation / Q000401:mortality; D016009:Chi-Square Distribution; D057867:Endoleak / Q000209:etiology / Q000401:mortality / Q000601:surgery; D057510:Endovascular Procedures / Q000009:adverse effects / Q000295:instrumentation / Q000401:mortality; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D053208:Kaplan-Meier Estimate; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D010414:Pennsylvania; D011474:Prosthesis Design; D011475:Prosthesis Failure; D012086:Reoperation; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D015607:Stents; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome