title: Comparative predictors of mortality for endovascular and open repair of ruptured infrarenal abdominal aortic aneurysms.
abstract: BACKGROUND
  The continued success of elective endovascular aneurysm repair (EVAR) has led to an extension of this technology to ruptured aortas. The purpose of this study was to evaluate our results of ruptured infrarenal aortic aneurysm (rAAA).
  
  
  METHODS
  The treatment results of all patients who underwent repair of rAAAs between January 1990 and May 2008 were reviewed retrospectively. Comorbidities, intraoperative details, and postoperative complications were tabulated. EVAR and open repair were compared.
  
  
  RESULTS
  Between January 1990 and May 2008, 160 patients underwent repair of rAAA. Of these, 32 (20%) underwent EVAR for rAAA; of 160 patients, 112 were considered to have free rupture (70%) and 48 had contained rupture (30%). The average Acute Physiology and Chronic Health Evaluation II score was 13.3 ± 6.7. The Kaplan-Meier survival rates at 30 days, 6 months, 1 year, and 5 years were 69% (62,77), 57% (50,65), 50% (43,59), and 25% (19,34), respectively, with no difference seen in EVAR group as compared with open surgery (p = 0.24). Intraoperative mortality was 5.6%, with no patient undergoing EVAR suffering an intraoperative death (p = 0.03). However, 30-day mortality was 31.9% with no difference between EVAR and open surgery (31.2% vs. 32%; p = 0.93) results. Multivariate analysis for 30-day mortality found renal insufficiency (RI) odds ratio (OR): 2.4 (1.1, 5.3), p = 0.04; hypotension OR: 2.4 (1.1, 5.3), p = 0.02; and cardiac arrest OR: 3.8 (1.1, 11.6, p = 0.03), were all associated with the greatest mortality. Of all predictors analyzed, multivariate analysis found preoperative RI OR: 2.32 (1.55, 3.47), p < 0.001, was the only independent predictor of decreased long-term survival.
  
  
  CONCLUSIONS
  Mortality rates for rAAA remain high. The use of EVAR for these procedures equals that for open repair with regard to 30-day and long-term mortality. Preoperative cardiac arrest and RI were associated with inferior results for both EVAR and open repair. Clinical judgment on when to use EVAR as a primary repair modality must be exercised.
authors.affiliation: Department of Vascular Surgery, Cleveland Clinic Lerner School of Medicine, Cleveland Clinic, Cleveland, OH, USA. saract@ccf.org
authors.forename: Timur P
authors.initials: TP
authors.lastname: Sarac
authors.forename: Mohsen
authors.initials: M
authors.lastname: Bannazadeh
authors.forename: A F
authors.initials: AF
authors.lastname: Rowan
authors.forename: James
authors.initials: J
authors.lastname: Bena
authors.forename: Sunita
authors.initials: S
authors.lastname: Srivastava
authors.forename: Mathew
authors.initials: M
authors.lastname: Eagleton
authors.forename: Sean
authors.initials: S
authors.lastname: Lyden
authors.forename: Daniel G
authors.initials: DG
authors.lastname: Clair
authors.forename: Vikram
authors.initials: V
authors.lastname: Kashyap
mesh_terms: D018806:APACHE; D000368:Aged; D000369:Aged, 80 and over; D017544:Aortic Aneurysm, Abdominal / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D001019:Aortic Rupture / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D001027:Aortography / Q000379:methods; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000401:mortality*; D016009:Chi-Square Distribution; D015897:Comorbidity; D057510:Endovascular Procedures / Q000009:adverse effects / Q000401:mortality*; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D053208:Kaplan-Meier Estimate; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D009820:Ohio; D018579:Patient Selection; D011183:Postoperative Complications / Q000209:etiology / Q000401:mortality; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome