title: Long-term outcome of ruptured abdominal aortic aneurysm: impact of treatment and age.
abstract: BACKGROUND
  Despite advances in operative repair, ruptured abdominal aortic aneurysm (rAAA) remains associated with high mortality and morbidity rates, especially in elderly patients. The purpose of this study was to evaluate the outcomes of emergency endovascular aneurysm repair (eEVAR), conventional open repair (OPEN), and conservative treatment in elderly patients with rAAA.
  
  
  METHODS
  We conducted a retrospective study of all rAAA patients treated with OPEN or eEVAR between January 2005 and December 2011 in the vascular surgery department at Amphia Hospital, the Netherlands. The outcome in patients treated for rAAA by eEVAR or OPEN repair was investigated. Special attention was paid to patients who were admitted and did not receive operative intervention due to serious comorbidity, extremely advanced age, or poor physical condition. We calculated the 30-day rAAA-related mortality for all rAAA patients admitted to our hospital.
  
  
  RESULTS
  Twelve patients did not receive operative emergency repair due to extreme fragility (mean age 87 years, median time to mortality 27 hours). Twenty-three patients had eEVAR and 82 had OPEN surgery. The 30-day mortality rate in operated patients was 30% (7/23) in the eEVAR group versus 26% (21/82) in the OPEN group (P=0.64). No difference in mortality was noted between eEVAR and OPEN over 5 years of follow-up. There were more cardiac adverse events in the OPEN group (n=25, 31%) than in the eEVAR group (n=2, 9%; P=0.035). Reintervention after discharge was more frequent in patients who received eEVAR (35%) than in patients who had OPEN (6%, P<0.001). Advancing age was associated with increasing mortality (hazard ratio 1.05 [95% confidence interval 1.01-1.09]) per year for patients who received operative repair, with a 67%, 76%, and 100% 5-year mortality rate in the 34 patients aged <70 years, 59 patients aged 70-79 years, and 12 octogenarians, respectively; 30-day rAAA-related mortality was also associated with increasing age (21%, 30%, and 61%, respectively; P=0.008).
  
  
  CONCLUSIONS
  The 30-day and 5-year mortality in patients who survived rAAA was equal between the treatment options of eEVAR and OPEN. Particularly fragile and very elderly patients did not receive operative repair. The decision to intervene in rAAA should not be made on the basis of patient age alone, but also in relation to comorbidity and patient preference.
authors.affiliation: Department of Surgery, Amphia Hospital, Breda, the Netherlands.
authors.forename: Jelle W
authors.initials: JW
authors.lastname: Raats
authors.affiliation: Department of Surgery, Amphia Hospital, Breda, the Netherlands.
authors.forename: Hans C
authors.initials: HC
authors.lastname: Flu
authors.affiliation: Department of Surgery, Amphia Hospital, Breda, the Netherlands.
authors.forename: Gwan H
authors.initials: GH
authors.lastname: Ho
authors.affiliation: Department of Surgery, Amphia Hospital, Breda, the Netherlands.
authors.forename: Eelco J
authors.initials: EJ
authors.lastname: Veen
authors.affiliation: Department of Radiology, Amphia Hospital, Breda, the Netherlands.
authors.forename: Louwerens D
authors.initials: LD
authors.lastname: Vos
authors.affiliation: Department of Public Health, Erasmus MC, Rotterdam, the Netherlands.
authors.forename: Ewout W
authors.initials: EW
authors.lastname: Steyerberg
authors.affiliation: Department of Surgery, Amphia Hospital, Breda, the Netherlands.
authors.forename: Lijckle
authors.initials: L
authors.lastname: van der Laan
mesh_terms: D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D017544:Aortic Aneurysm, Abdominal / Q000401:mortality / Q000601:surgery*; D001019:Aortic Rupture / Q000401:mortality / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation; D002423:Cause of Death; D015897:Comorbidity; D004630:Emergencies; D057510:Endovascular Procedures; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D011183:Postoperative Complications / Q000209:etiology / Q000401:mortality; D016016:Proportional Hazards Models; D012086:Reoperation; D012189:Retrospective Studies; D015607:Stents; D014656:Vascular Surgical Procedures
keywords: clinical decision-making; emergency endovascular aneurysm repair; open repair; ruptured abdominal aneurysm repair