title: Early and delayed rupture after endovascular abdominal aortic aneurysm repair in a 10-year multicenter registry.
abstract: OBJECTIVE
  Rupture after abdominal endovascular aortic aneurysm repair (EVAR) is a function of graft maintenance of the seal and fixation. We describe our 10-year experience with rupture after EVAR.
  
  
  METHODS
  From 2000 to 2010, 1736 patients with abdominal aortic aneurysm (AAA) from 17 medical centers underwent EVAR in a large, regional integrated health care system. Preoperative demographic and clinical data of interest were collected and stored in our registry. We retrospectively identified patients with postoperative rupture, characterized as "early" and "delayed" rupture (≤30 days and >30 days after the initial EVAR, respectively), and identified predictors associated with delayed rupture.
  
  
  RESULTS
  The overall follow-up rate was 92%, and the median follow-up was 2.7 years (interquartile range, 1.2-4.4 years) in these 1736 EVAR patients. We identified 20 patients with ruptures; 70% were male, the mean age was 79 years, and mean AAA size at the initial EVAR was 6.3 cm. Six patients underwent initial EVAR for rupture (n = 2) or symptomatic presentation (n = 4). Of the 20 post-EVAR ruptures, 25% (five of 20) were early, all occurring within 2 days after the initial EVAR. Of these five patients, four had intraoperative adverse events leading directly to rupture, with one type I and one type III endoleak. Of the five early ruptures, four patients underwent endovascular repair and one received repair with open surgery, resulting in two perioperative deaths. Among the remaining 15 patients, the median time from initial EVAR to rupture was 31.1 months (interquartile range, 13.8-57.3 months). Most of these delayed ruptures (10 of 15) were preceded by AAA sac increases, including three patients with known endoleaks who underwent reintervention. At the time of delayed rupture, nine of 15 patients had new endoleaks. Among all 20 patients, six patients did not undergo repair (all delayed patients) and died, nine underwent repeated EVAR, and five had open repair. For patients who underwent repair for delayed rupture, mortality at 30 days and 1 year were 44.4% and 66.7%, respectively. Multivariable Cox regression analysis identified age 80 to 89 (hazard ratio, 3.3; 95% confidence interval, 1.1-9.4; P = .03), and symptomatic or ruptured initial indication for EVAR (hazard ratio, 7.4; 95% confidence interval, 2.2-24.8; P < .01) as significant predictors of delayed rupture.
  
  
  CONCLUSIONS
  Rupture after EVAR is a rare but devastating event, and mortality after repair exceeds 60% at 1 year. Most delayed cases showed late AAA expansion, thereby implicating late loss of seal and increased endoleaks as the cause of rupture in these patients and mandating vigilant surveillance.
authors: East Bay Surgical Residency Program, University of California, San Francisco, Oakland, Calif.
authors: Leah
authors: L
authors: Candell
authors: Division of Research, Kaiser Permanente, Oakland, Calif.
authors: Lue-Yen
authors: LY
authors: Tucker
authors: Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
authors: Philip
authors: P
authors: Goodney
authors: General Surgery Residency Program, University of California, San Francisco, San Francisco, Calif.
authors: Joy
authors: J
authors: Walker
authors: Department of Vascular Surgery, Permanente Medical Group, San Francisco, Calif.
authors: Steven
authors: S
authors: Okuhn
authors: Department of Vascular Surgery, Permanente Medical Group, Santa Clara, Calif.
authors: Bradley
authors: B
authors: Hill
authors: Department of Vascular and Endovascular Surgery, Permanente Medical Group, South San Francisco, Calif. Electronic address: robert.w.chang@kp.org.
authors: Robert
authors: R
authors: Chang
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D017544:Aortic Aneurysm, Abdominal / Q000150:complications / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D001019:Aortic Rupture / Q000175:diagnosis / Q000209:etiology* / Q000401:mortality / Q000601:surgery; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects* / Q000401:mortality; D016009:Chi-Square Distribution; D057867:Endoleak / Q000175:diagnosis / Q000209:etiology* / Q000401:mortality / Q000601:surgery; D057510:Endovascular Procedures / Q000009:adverse effects* / Q000401:mortality; D005260:Female; D006801:Humans; D008297:Male; D015999:Multivariate Analysis; D016016:Proportional Hazards Models; D012042:Registries; D012086:Reoperation; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States