Late Rupture of Abdominal Aortic Aneurysm After Previous Endovascular Repair: A Systematic Review and Meta-analysis.
OBJECTIVE
To report a systematic literature review of late rupture of abdominal aortic aneurysm (AAA) after endovascular aneurysm repair (EVAR) and the results of a pooled analysis of causes, treatment, and outcomes.


METHODS
Electronic information sources and bibliographic reference lists were interrogated using a combination of free text and controlled vocabulary searches; 11 articles were ultimately identified that fulfilled the inclusion criteria. The articles reported a total of 190 patients who were included in the qualitative and quantitative synthesis. Mortality within 30 days or during the admission with aneurysm rupture was a primary endpoint; major perioperative morbidity was a secondary endpoint. A meta-analysis was performed for 30-day/in-hospital mortality using the random effects model.


RESULTS
A total of 152 ruptures occurred after 16,974 EVAR procedures reported by 8 of the case series, giving an incidence of 0.9% [95% confidence interval (CI) 0.77 to 1.05]. The mean time to rupture was 37 months. Twenty-nine percent (95% CI 20 to 39) of the patients had at least one previous secondary endovascular intervention following the initial EVAR, and 37% (95% CI 30 to 45) were not compliant with surveillance. Type I and III endoleaks were the predominant causes of rupture. Open surgical treatment was undertaken in 61% (95% CI 53 to 68) of the patients who underwent treatment. The pooled estimate for perioperative mortality was 32% (95% CI 24 to 41). A significantly lower mortality was found with endovascular treatment than open surgical management (p=0.027).


CONCLUSIONS
Graft-related endoleaks appear to be the predominant causes of late aneurysm rupture. Quality of and compliance with post-EVAR surveillance are important factors in late rupture; a large proportion of late ruptures are amenable to endovascular treatment.
Liverpool Vascular and Endovascular Service, Royal Liverpool University Hospital, Liverpool, UK antoniou.ga@hotmail.com.
George A
GA
Antoniou
Department of Vascular and Endovascular Surgery, University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece.
George S
GS
Georgiadis
Department of Surgery, University Hospital of Heraklion, University of Crete, Heraklion, Greece.
Stavros A
SA
Antoniou
Liverpool Vascular and Endovascular Service, Royal Liverpool University Hospital, Liverpool, UK.
Simon
S
Neequaye
Liverpool Vascular and Endovascular Service, Royal Liverpool University Hospital, Liverpool, UK.
John A
JA
Brennan
Liverpool Vascular and Endovascular Service, Royal Liverpool University Hospital, Liverpool, UK.
Francesco
F
Torella
Liverpool Vascular and Endovascular Service, Royal Liverpool University Hospital, Liverpool, UK.
S Rao
SR
Vallabhaneni
D017544:Aortic Aneurysm, Abdominal / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D001019:Aortic Rupture / Q000175:diagnosis / Q000209:etiology* / Q000401:mortality / Q000628:therapy; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects* / Q000401:mortality; D057867:Endoleak / Q000175:diagnosis / Q000209:etiology* / Q000401:mortality / Q000628:therapy; D057510:Endovascular Procedures / Q000009:adverse effects* / Q000401:mortality; D017052:Hospital Mortality; D006801:Humans; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome
abdominal aortic aneurysm; aneurysm rupture; complications; conversion; endoleak; endovascular aneurysm repair; meta-analysis; mortality; open repair; secondary interventions; stent-graft; surveillance