In patients stratified by preoperative risk, endovascular repair of ruptured abdominal aortic aneurysms has a lower in-hospital mortality and morbidity than open repair.
OBJECTIVE
Previous studies have reported that endovascular repair (EVAR) of ruptured abdominal aortic aneurysms (RAAAs) has lower postoperative mortality than open repair (OR). However, comparisons involved heterogeneous populations that lacked adjustment for preoperative risk. We hypothesize that for RAAA patients stratified by a validated measure of preoperative mortality risk, EVAR has a lower in-hospital mortality and morbidity than does OR.


METHODS
In-hospital mortality and morbidity after EVAR and OR of RAAA were compared in patients from the Vascular Quality Initiative (2003-2013) stratified by the validated Vascular Study Group of New England RAAA risk score into low-risk (score 0-1), medium-risk (score 2-3), and high-risk (score 4-6) groups.


RESULTS
Among 514 patients who underwent EVAR and 651 patients who underwent OR of RAAA, EVAR had lower in-hospital mortality (25% vs 33%, P = .001). In risk-stratified patients, EVAR trended toward a lower mortality in the low-risk group (n = 626; EVAR, 10% vs OR, 15%; P = .07), had a significantly lower mortality in the medium-risk group (n = 457; EVAR, 37% vs OR, 48%; P = .02), and no advantage in the high-risk group (n = 82; EVAR, 95% vs OR, 79%; P = .17). Across all risk groups, cardiac complications (EVAR, 29% vs OR, 38%; P = .001), respiratory complications (EVAR, 28% vs OR, 46%; P < .0001), renal insufficiency (EVAR, 24% vs OR, 38%; P < .0001), lower extremity ischemia (EVAR, 2.7% vs OR, 8.1%; P < .0001), and bowel ischemia (EVAR, 3.9% vs OR, 10%; P < .0001) were significantly lower after EVAR than after OR. Across all risk groups, median (interquartile range) intensive care unit length of stay (EVAR, 2 [1-5] days vs OR, 6 [3-13] days; P < .0001) and hospital length of stay (EVAR, 6 [4-12] days vs OR, 13 [8-22] days; P < .0001) were lower after EVAR.


CONCLUSIONS
This novel risk-stratified comparison using a national clinical database showed that EVAR of RAAA has a lower mortality and morbidity compared with OR in low-risk and medium-risk patients and that EVAR should be used to treat these patients when anatomically feasible. For RAAA patients at the highest preoperative risk, there is no benefit to using EVAR compared with OR.
Division of Vascular & Endovascular Surgery, University of Massachusetts Medical School, Worcester, Mass.
Mujtaba M
MM
Ali
Center for Outcomes Research, Department of Surgery, University of Massachusetts Medical School, Worcester, Mass.
Julie
J
Flahive
Division of Vascular & Endovascular Surgery, University of Massachusetts Medical School, Worcester, Mass.
Andres
A
Schanzer
Division of Vascular & Endovascular Surgery, University of Massachusetts Medical School, Worcester, Mass.
Jessica P
JP
Simons
Division of Vascular & Endovascular Surgery, University of Massachusetts Medical School, Worcester, Mass.
Francesco A
FA
Aiello
Division of Vascular & Endovascular Surgery, University of Massachusetts Medical School, Worcester, Mass.
Danielle R
DR
Doucet
Division of Vascular & Endovascular Surgery, University of Massachusetts Medical School, Worcester, Mass.
Louis M
LM
Messina
Division of Vascular & Endovascular Surgery, University of Massachusetts Medical School, Worcester, Mass. Electronic address: william.robinson@umassmemorial.org.
William P
WP
Robinson
D000368:Aged; D017544:Aortic Aneurysm, Abdominal / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D001019:Aortic Rupture / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects* / Q000401:mortality*; D016009:Chi-Square Distribution; D016208:Databases, Factual; D057510:Endovascular Procedures / Q000009:adverse effects* / Q000401:mortality*; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007902:Length of Stay; D016015:Logistic Models; D008297:Male; D016017:Odds Ratio; D011183:Postoperative Complications / Q000401:mortality* / Q000628:therapy; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology