Association of an Endovascular-First Protocol for Ruptured Abdominal Aortic Aneurysms With Survival and Discharge Disposition.

IMPORTANCE Mortality after an open surgical repair of a ruptured abdominal aortic aneurysm (rAAA) remains high. The role and clinical benefit of ruptured endovascular aneurysm repair (rEVAR) have yet to be fully elucidated. OBJECTIVE To evaluate the effect of an endovascular-first protocol for patients with an rAAA on perioperative mortality and associated early clinical outcomes. DESIGN, SETTING, AND PARTICIPANTS Retrospective review of a consecutive series of patients presenting with an rAAA before (1997-2006) and after (2007-2014) implementation of an endovascular-first treatment strategy (ie, protocol) at an academic medical center. MAIN OUTCOMES AND MEASURES Early mortality, perioperative morbidity, discharge disposition, and overall survival. RESULTS A total of 88 patients with an rAAA were included in the analysis, including 46 patients in the preprotocol group (87.0% underwent an open repair and 13.0% underwent an rEVAR) and 42 patients in the intention-to-treat postprotocol group (33.3% underwent an open repair and 66.7% underwent an rEVAR; P = .001). Baseline demographics were similar between groups. Postprotocol patients died significantly less often at 30 days (14.3% vs 32.6%; P = .03), had a decreased incidence of major complications (45.0% vs 71.8%; P = .02), and had a greater likelihood of discharge to home (69.2% vs 42.1%; P = .04) after rAAA repair compared with preprotocol patients. Kaplan-Meier analysis demonstrated significantly greater long-term survival in the postprotocol period (log-rank P = .002). One-, 3-, and 5-year survival rates were 50.0%, 45.7%, and 39.1% for open repair, respectively, and 61.9%, 42.9%, and 23.8% for rEVAR, respectively. CONCLUSIONS AND RELEVANCE Implementation of a contemporary endovascular-first protocol for the treatment of an rAAA is associated with decreased perioperative morbidity and mortality, a higher likelihood of discharge to home, and improved long-term survival. Patients with an rAAA and appropriate anatomy should be offered endovascular repair as first-line treatment at experienced vascular centers.

[1]  K. Tran,et al.  Association of an Endovascular-First Protocol for Ruptured Abdominal Aortic Aneurysms With Survival and Discharge Disposition , 2016 .

[2]  T. F. Rehring,et al.  Endovascular repair of ruptured and symptomatic abdominal aortic aneurysms using a structured protocol in a community teaching hospital. , 2015, Annals of vascular surgery.

[3]  Improve trial investigators,et al.  Endovascular or open repair strategy for ruptured abdominal aortic aneurysm: 30 day outcomes from IMPROVE randomised trial , 2014, BMJ : British Medical Journal.

[4]  T. Hatsukami,et al.  Favorable discharge disposition and survival after successful endovascular repair of ruptured abdominal aortic aneurysm. , 2013, Journal of vascular surgery.

[5]  T. Pfammatter,et al.  Complete Replacement of Open Repair for Ruptured Abdominal Aortic Aneurysms by Endovascular Aneurysm Repair. A Two-Center 14-Year Experience , 2013 .

[6]  Taeyoung Park,et al.  Endovascular repair of ruptured abdominal aortic aneurysm does not confer survival benefits over open repair. , 2012, Journal of vascular surgery.

[7]  R. Dalman,et al.  Early experience with the snorkel technique for juxtarenal aneurysms. , 2012, Journal of vascular surgery.

[8]  J. Sosa,et al.  Endovascular Repair Is Associated With Superior Clinical Outcomes in Patients Transferred for Treatment of Ruptured Abdominal Aortic Aneurysms , 2012, Journal of endovascular therapy : an official journal of the International Society of Endovascular Specialists.

[9]  R. Chagpar,et al.  Early Mortality Following Endovascular Versus Open Repair of Ruptured Abdominal Aortic Aneurysms , 2010, Vascular and endovascular surgery.

[10]  D. Davenport,et al.  Thirty-day NSQIP database outcomes of open versus endoluminal repair of ruptured abdominal aortic aneurysms. , 2010, Journal of vascular surgery.

[11]  T. Hatsukami,et al.  Management of ruptured abdominal aortic aneurysm in the endovascular era. , 2010, Journal of vascular surgery.

[12]  M. Lachat,et al.  Collected World and Single Center Experience With Endovascular Treatment of Ruptured Abdominal Aortic Aneurysms , 2009, Annals of surgery.

[13]  N. Cheshire,et al.  Endovascular repair of ruptured abdominal aortic aneurysm: A strategy in need of definitive evidence. , 2009, Journal of vascular surgery.

[14]  C. Clase,et al.  Endovascular repair of ruptured abdominal aortic aneurysms: a systematic review and meta-analysis. , 2008, Journal of vascular surgery.

[15]  Mona Motamedi,et al.  Improved survival after introduction of an emergency endovascular therapy protocol for ruptured abdominal aortic aneurysms. , 2007, Journal of vascular surgery.

[16]  S. Acosta,et al.  Increasing incidence of ruptured abdominal aortic aneurysm: a population-based study. , 2006, Journal of vascular surgery.

[17]  P. Kreienberg,et al.  Establishing a protocol for endovascular treatment of ruptured abdominal aortic aneurysms: outcomes of a prospective analysis. , 2006, Journal of vascular surgery.

[18]  Roger Resar,et al.  Using a bundle approach to improve ventilator care processes and reduce ventilator-associated pneumonia. , 2005, Joint Commission journal on quality and patient safety.

[19]  Erik Buskens,et al.  A randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms. , 2004, The New England journal of medicine.

[20]  A. Sutton,et al.  A meta‐analysis of 50 years of ruptured abdominal aortic aneurysm repair , 2002, The British journal of surgery.

[21]  J. Parodi,et al.  Initial Experience with Transluminally Placed Endovascular Grafts for the Treatment of Complex Vascular Lesions , 1995, Annals of surgery.