To Örebro University

PURPOSE: To compare endovascular aneurysm repair (EVAR) of ruptured abdominal aortic aneurysms (rAAA) to the results with open surgery.

METHODS: Between May 2001 and January 2004, 50 patients were diagnosed with rAAA. Fifteen (30%) patients (14 men; median age 73 years, range 58-85) underwent EVAR, while 26 (52%) patients (23 men; median age 75 years, range 60-84) had open surgery. Nine (18%) patients (5 men; median age 86 years, range 77-91) were not operated upon. Circulatory shock was defined as systolic blood pressure<80 mmHg. Mortality was defined as death within 30 days after operation; in cases where hospital stay exceeded 30 days, in-hospital mortality was registered. Five risk factors (age>76 years, loss of consciousness, hemoglobin<90 g/L, creatinine>190 micromol/L, and electrocardiographic ischemia) were analyzed.

RESULTS: In the EVAR group, 93% (14/15) of the aneurysms were excluded from the bloodstream; there were 2 (13%) conversions: 1 intraoperatively for stent-graft migration and another owing to dissection prior to hospital discharge. Mortality after open surgery was 46% (12/26) versus 13% (2/15) in the EVAR group (p>0.05). Univariate analysis without considering variables other than mortality resulted in OR 5.4 (95% CI 0.9 to 58; p=0.07). Considering risk factors and shock, multivariate analysis resulted in OR 6.5 (95% CI 0.8 to 96; p=0.08). In the EVAR group, 60% (9/15) had complications; in the group with open surgery, the complication rate was 85% (22/26; p=0.13).

CONCLUSIONS: It is possible to treat rAAA with EVAR. Hypotensive patients can, at least initially, be operated under local anesthesia to stabilize blood pressure utilizing a percutaneously inserted occlusion balloon. There was a trend in our study for reduced mortality and morbidity with EVAR, but further studies are required to conclude whether EVAR significantly increases survival and reduces complications.

PURPOSE: To evaluate a technique for closure of a femoral artery access in which the cribriform fascia covering the common femoral artery is sutured.

METHODS: A consecutive series of 127 patients (103 men; median age 74 years, range 45- 89) underwent endovascular aortic aneurysm repair between August 2001 and September 2004. Twelve patients underwent a secondary intervention for a total of 139 procedures in the group. Sixty-one (43.9%) of the 139 operations were acute. Among the 257 femoral arteries used for access, a fascia suturing technique was performed in 131 (51.0%). Data were collected for analysis of access site complications, bleeding, thrombosis, pseudoaneurysm, and stenosis. A subgroup of 72 patients had ankle-brachial indexes (ABI) recorded; another subgroup of 50 patients were also investigated by duplex ultrasonography.

RESULTS: Complications occurred in 18 (13.7%) of the 131 sutured cases. The majority (n = 16) arose within 24 hours: 8 cases of perioperative bleeding or thrombosis required open surgery and 8 cases were reoperated within 24 hours for bleeding (n = 4), thrombosis (n = 3), and 1 intimal dissection. The acute failure rate was 12.2%. Two patients had late complications: 1 case of neuralgia and 1 pseudoaneurysm that required acute surgery 28 months postoperatively. The ABI did not change significantly from pre- to postoperatively in the 72 patients examined. Five patients with stenoses did not have a reduction in ABI. In the 66 sites examined with ultrasound in 50 patients, 3 minor pseudoaneurysms were detected.

CONCLUSION: The fascia suturing technique for closure of a femoral artery access during endovascular repair of aortic diseases is feasible, even in acute situations. Failures can be managed easily. Late complications requiring additional procedures are rare.

Objective: To present the combined 14-year experience of 2 university centers performing endovascular aneurysm repair (EVAR) on 100% of noninfected ruptured abdominal aortic aneurysms (RAAA) over the last 32 months.

Background: : Endovascular aneurysm repair for RAAA feasibility is reported to be 20% to 50%, and EVAR for RAAA has been reported to have better outcomes than open repair.

Methods: We retrospectively analyzed prospectively gathered data on 473 consecutive RAAA patients (Zurich, 295; Örebro, 178) from January 1, 1998, to December 31, 2011, treated by an "EVAR-whenever-possible" approach until April 2009 (EVAR/OPEN period) and thereafter according to a "100% EVAR" approach (EVAR-ONLY period).Straightforward cases were treated by standard EVAR. More complex RAAA were managed during EVAR-ONLY with adjunctive procedures in 17 of 70 patients (24%): chimney, 3; open iliac debranching, 1; coiling, 8; onyx, 3; and chimney plus onyx, 2.

Results: Since May 2009, all RAAA but one have been treated by EVAR (Zurich, 31; Örebro, 39); 30-day mortality for EVAR-ONLY was 24% (17 of 70). Total cohort mortality (including medically treated patients) for EVAR/OPEN was 32.8% (131 of 400) compared with 27.4% (20 of 73) for EVAR-ONLY (P = 0.376). During EVAR/OPEN, 10% (39 of 400) of patients were treated medically compared with 4% (3 of 73) of patients during EVAR-ONLY. In EVAR/OPEN, open repair showed a statistically significant association with 30-day mortality (adjusted odds ratio [OR] = 3.3; 95% confidence interval [CI], 1.4-7.5; P = 0.004). For patients with no abdominal decompression, there was a higher mortality with open repair than EVAR (adjusted OR = 5.6; 95% CI, 1.9-16.7). In patients with abdominal decompression by laparotomy, there was no difference in mortality (adjusted OR = 1.1; 95% CI, 0.3-3.7).

Conclusions: The "EVAR-ONLY" approach has allowed EVAR treatment of nearly all incoming RAAA with low mortality and turndown rates. Although the observed association of a higher EVAR mortality with abdominal decompression needs further study, our results support superiority and more widespread adoption of EVAR for the treatment of RAAA.