Operative Mortality and Morbidity in Ruptured Abdominal Aortic Aneurysms in the Endovascular Age

Abstract

Background: Controversy exists about technique of repair for ruptured abdominal aortic aneurysms (rAAA). We studied rAAA treated at a single tertiary center from 2005 to 2015 to determine operative morbidity and mortality in open and endovascular aortic aneurysm repair (EVAR) of rAAA.

Methods: All rAAA (n = 144) treated from 2005 to 2015 were reviewed using an IRB-approved database. "EVAR first" strategy was used after 2010. rAAA treatment was open (rAAA began with open surgery); EVAR (rAAA began with EVAR and included EVARs converted to open); and EVAR only (successful EVAR). Preoperative, intraoperative and outcome variables were analyzed with t-test, chi-square and logistic and multivariate regression using SAS.

Results: One hundred forty-four rAAAs were treated from 2005 to 2015. Seventy-five percent (108/144) began with open surgery. Twenty-five percent (36/144) began with EVAR. After 2010, 54.5% began with EVAR. Eleven percent of EVARs (4/36) converted to open and 89% (32/36) had EVAR only. Fifty-nine percent (83/144) had preoperative systolic blood pressure (SBP) <90 mm Hg. Eighty-four percent of these (70/83) had open surgery and 16% (13/83) had EVAR. Hospital mortality for all rAAAs was 23.6% (34/144). Operative mortality was 25% (27/108) in open and 19.4% (7/36) in EVAR (P = 0.486). Mortality was 75% (3/4) in EVARs that converted to open and 12.5% (4/32) in EVAR only patients. In univariate analysis age, ASA 5, preoperative SBP <90 mm Hg, intraoperative complications, dialysis, MI/CHF, respiratory failure, stroke and reintervention were significant for mortality. In multivariate modeling preoperative SBP <90 mm Hg (P = 0.0018), ASA 5 (P = 0.0175), intraoperative complications (P = 0.0017), MI/CHF (P = 0.0045), respiratory failure (P = 0.0159) and new renal failure (P = 0.0073) were significant for mortality. There was no difference in mortality between open and EVAR (P = 0.9554) and no difference in cardiac or respiratory failure. Open had more renal failure and EVAR more endoleaks. Fifty-eight percent (21/36) of EVARs started with local anesthesia (LA) and 52.8% (19/36) finished with LA. Nineteen percent (4/21) of EVARs with LA versus 60% (9/15) with general anesthesia (GA) had preoperative SBP <90 mm Hg. In EVAR only there was no difference in mortality between LA (4/18, 22.2%) and GA (3/14, 21.4%) (P = 0.94).

Conclusions: Operative mortality in ruptured AAA was associated with hypotension, ASA status 5, uncontrolled hemorrhage, cardiac events, and respiratory failure but not with type of repair. EVAR and open surgery also had comparable cardiac and respiratory morbidity. Selection was critical in EVAR for rAAA because mortality of unsuccessful EVAR was very high. There was no difference in mortality between LA and GA for EVAR.