title: Complete replacement of open repair for ruptured abdominal aortic aneurysms by endovascular aneurysm repair: a two-center 14-year experience.
abstract: OBJECTIVE
  To present the combined 14-year experience of 2 university centers performing endovascular aneurysm repair (EVAR) on 100% of noninfected ruptured abdominal aortic aneurysms (RAAA) over the last 32 months.
  
  
  BACKGROUND
  Endovascular aneurysm repair for RAAA feasibility is reported to be 20% to 50%, and EVAR for RAAA has been reported to have better outcomes than open repair.
  
  
  METHODS
  We retrospectively analyzed prospectively gathered data on 473 consecutive RAAA patients (Zurich, 295; Örebro, 178) from January 1, 1998, to December 31, 2011, treated by an "EVAR-whenever-possible" approach until April 2009 (EVAR/OPEN period) and thereafter according to a "100% EVAR" approach (EVAR-ONLY period).Straightforward cases were treated by standard EVAR. More complex RAAA were managed during EVAR-ONLY with adjunctive procedures in 17 of 70 patients (24%): chimney, 3; open iliac debranching, 1; coiling, 8; onyx, 3; and chimney plus onyx, 2.
  
  
  RESULTS
  Since May 2009, all RAAA but one have been treated by EVAR (Zurich, 31; Örebro, 39); 30-day mortality for EVAR-ONLY was 24% (17 of 70). Total cohort mortality (including medically treated patients) for EVAR/OPEN was 32.8% (131 of 400) compared with 27.4% (20 of 73) for EVAR-ONLY (P = 0.376). During EVAR/OPEN, 10% (39 of 400) of patients were treated medically compared with 4% (3 of 73) of patients during EVAR-ONLY. In EVAR/OPEN, open repair showed a statistically significant association with 30-day mortality (adjusted odds ratio [OR] = 3.3; 95% confidence interval [CI], 1.4-7.5; P = 0.004). For patients with no abdominal decompression, there was a higher mortality with open repair than EVAR (adjusted OR = 5.6; 95% CI, 1.9-16.7). In patients with abdominal decompression by laparotomy, there was no difference in mortality (adjusted OR = 1.1; 95% CI, 0.3-3.7).
  
  
  CONCLUSIONS
  The "EVAR-ONLY" approach has allowed EVAR treatment of nearly all incoming RAAA with low mortality and turndown rates. Although the observed association of a higher EVAR mortality with abdominal decompression needs further study, our results support superiority and more widespread adoption of EVAR for the treatment of RAAA.
authors.affiliation: Clinic for Cardiovascular Surgery, University Hospital of Zurich, Zurich, Switzerland.
authors.forename: D
authors.initials: D
authors.lastname: Mayer
authors.forename: S
authors.initials: S
authors.lastname: Aeschbacher
authors.forename: T
authors.initials: T
authors.lastname: Pfammatter
authors.forename: F J
authors.initials: FJ
authors.lastname: Veith
authors.forename: L
authors.initials: L
authors.lastname: Norgren
authors.forename: A
authors.initials: A
authors.lastname: Magnuson
authors.forename: Z
authors.initials: Z
authors.lastname: Rancic
authors.forename: M
authors.initials: M
authors.lastname: Lachat
authors.forename: T
authors.initials: T
authors.lastname: Hörer
authors.forename: P
authors.initials: P
authors.lastname: Skoog
authors.forename: T
authors.initials: T
authors.lastname: Larzon
mesh_terms: D000368:Aged; D000465:Algorithms; D017542:Aneurysm, Ruptured / Q000401:mortality / Q000601:surgery*; D017544:Aortic Aneurysm, Abdominal / Q000401:mortality / Q000601:surgery*; D016009:Chi-Square Distribution; D057510:Endovascular Procedures / Q000379:methods* / Q000401:mortality; D005260:Female; D006801:Humans; D008297:Male; D012189:Retrospective Studies; D015996:Survival Rate; D013548:Sweden / Q000453:epidemiology; D013557:Switzerland / Q000453:epidemiology; D016896:Treatment Outcome