title: Endovascular repair of ruptured abdominal aortic aneurysms does not reduce later mortality compared with open repair.
abstract: OBJECTIVE
  Endovascular aneurysm repair (EVAR) of ruptured abdominal aortic aneurysms (RAAAs) reduces in-hospital mortality compared with open repair (OR), but it is unknown whether EVAR reduces long-term mortality. We hypothesized that EVAR of RAAA would independently reduce long-term mortality compared with OR.
  
  
  METHODS
  The Vascular Quality Initiative database (2003-2013) was used to determine Kaplan-Meier 1-year and 5-year mortality after EVAR and OR of RAAA. Multivariate analysis was performed to identify patient and operative characteristics associated with mortality at 1 year and 5 years after RAAA repair.
  
  
  RESULTS
  Among 590 patients who underwent EVAR and 692 patients who underwent OR of RAAA, the lower mortality seen in the hospital after EVAR (EVAR 23% vs OR 35%; P < .001) persisted at 1 year (EVAR 34% vs OR 42%; P = .001) and 5 years (EVAR 50% vs OR 58%; P = .003) after repair. After adjusting for patient and operative characteristics, EVAR did not independently reduce mortality at 1 year (hazard ratio [HR], 0.88; 95% confidence interval [CI], 0.7-1.1) or 5 years (HR, 0.95; 95% CI, 0.77-1.2) compared with OR. Dialysis dependence (HR, 3.9; 95% CI, 1.8-8.6), home oxygen use (HR, 1.9; 95% CI, 1.3-2.7), cardiac ejection fraction <50% (HR, 1.5; 95% CI, 1.03-2.1), female gender (HR, 1.3; 95% CI, 1.04-1.6), and age (HR, 1.06; 95% CI, 1.05-1.08 per 5 years) as well as cardiac arrest (HR, 3.4; 95% CI, 2.5-4.5), loss of consciousness (HR, 1.7; 95% CI, 1.3-2.2), and preoperative systolic blood pressure <90 mm Hg (HR, 1.4; 95% CI, 1.1-1.8) on admission predicted mortality at 1 year and 5 years after RAAA repair. Type I endoleak (HR, 2.2; 95% CI, 1.2-3.8) also predicted mortality at 1 year.
  
  
  CONCLUSIONS
  EVAR does not independently reduce long-term mortality compared with OR. Patient comorbidities and indices of shock on admission are the primary independent determinants of long-term mortality. However, the lower early mortality observed in the Vascular Quality Initiative for patients selected to undergo EVAR of RAAA compared with patients selected for OR is sustained over time, suggesting that EVAR for RAAA is beneficial in appropriate candidates. Better elucidation of the key selection factors, including aneurysm anatomy, is needed to best select patients for EVAR and OR to reduce long-term mortality.
authors.affiliation: Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester, Mass. Electronic address: wprobins3@gmail.com.
authors.forename: William P
authors.initials: WP
authors.lastname: Robinson
authors.affiliation: Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester, Mass.
authors.forename: Andres
authors.initials: A
authors.lastname: Schanzer
authors.affiliation: Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester, Mass.
authors.forename: Francesco A
authors.initials: FA
authors.lastname: Aiello
authors.affiliation: Center for Outcomes Research, Department of Surgery, University of Massachusetts Medical School, Worcester, Mass.
authors.forename: Julie
authors.initials: J
authors.lastname: Flahive
authors.affiliation: Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester, Mass.
authors.forename: Jessica P
authors.initials: JP
authors.lastname: Simons
authors.affiliation: Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester, Mass.
authors.forename: Danielle R
authors.initials: DR
authors.lastname: Doucet
authors.affiliation: Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester, Mass.
authors.forename: Elias
authors.initials: E
authors.lastname: Arous
authors.affiliation: Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester, Mass.
authors.forename: Louis M
authors.initials: LM
authors.lastname: Messina
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; 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; D015897:Comorbidity; D016208:Databases, Factual; D057510:Endovascular Procedures / Q000009:adverse effects / Q000401:mortality*; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D015999:Multivariate Analysis; D009656:North America / Q000453:epidemiology; D018579:Patient Selection; D016016:Proportional Hazards Models; D018570:Risk Assessment; D012307:Risk Factors; D012769:Shock / Q000401:mortality; D013997:Time Factors; D016896:Treatment Outcome