Endovascular-first treatment strategy improves outcomes after ruptured AAA

Patients with a ruptured abdominal aortic aneurysm (AAA) who underwent an endovascular-first treatment strategy at Stanford University Medical Center had reductions in perioperative morbidity and mortality and improvements in long-term survival compared with those who had an open repair.

Lead researcher Brant W. Ullery, MD, and his colleagues from Stanford published their results online in JAMA Surgery on Aug. 5.

For patients with evidence of a ruptured aneurysm, the mortality is approximately 80 percent, according to Ullery. Among patients who reach the hospital and undergo an open repair, the mortality is 30 percent to 50 percent.

“The fact that we at Stanford as well as a couple of other centers have been able to show reductions in mortality below 20 percent is unheard of in the setting of a ruptured aneurysm in the 50 years that we’ve done surgeries for this type of patient,” Ullery told Cardiovascular Business. “These are people who are coming in that are minutes to hours from death.”

The researchers analyzed data from 88 patients with a ruptured AAA who were treated at Stanford between July 1997 and July 2014. In 2007, Stanford implemented an endovascular-first algorithm, in which patients underwent an eligibility assessment for an intention-to-treat endovascular aneurysm repair (EVAR) protocol. Before then, most patients underwent open repair.

Patients who were treated from 1997 to 2007 were considered the preprotocol group, while patients who underwent surgery from 2007 to 2014 were deemed as the postprotocol group. At baseline, the groups were similar.

The researchers found that 13 percent of patients in the preprotocol group and 66.7 percent of patients in the postprotocol group underwent EVAR. The rest had open repair.

Within 30 days of the procedure, 14.3 percent of patients in the postprotocol group and 32.6 percent of patients in the preprotocol group died, while 45.0 percent and 71.8 percent of patients, respectively, had major complications.

The 1-, 3- and 5-year survival rates were 50 percent, 45.7 percent and 39.1 percent for open repair, respectively, and 61.9 percent, 42.9 percent and 23.8 percent for EVAR.

Ullery said that other hospitals have seen a similar trend toward more EVAR procedures in the high-risk, ruptured AAA populations. He mentioned the University of Washington and Albany Medical Center as other premier, high-volume centers that have a structured, algorithmic approach to these patients.

Since the mid-2000s, after research showed promising clinical outcomes with and increasing utilization of EVAR for elective practices, surgeons were more likely to perform EVAR in patients with ruptured AAA.

“The results [in patients with ruptured AAA] were almost as good as that in elective,” Ullery said. “We saw an abrupt decline in perioperative morbidity and mortality which has been unseen in the ruptured aneurysm literature for decades.”

As of now, there is a lack of randomized, controlled trials comparing the EVAR and open repair approaches because patients are close to death after their ruptured aneurysms. However, Ullery said EVAR has been shown to be the superior approach.

“The level of data that we have seems to highlight the fact that an endovascular-first approach is the best solution,” he said. “Based on the available literature as well as anecdotal evidence and experience throughout the country, I think it’s pretty uniform that people will embrace the endovascular-first approach for all ruptures.”