student research day - Case Western Reserve University School of ...

F. Andrew Rowan
EVAR vs. Open Surgery for Ruptured Abdominal Aortic Aneurysms
F. Andrew Rowan, Mohsen Bannazadeh MD, Vikram Kashyap MD, James Bena, Daniel Clair MD and Timur Sarac
MD
Vascular Surgery
The Cleveland Clinic Foundation
Objective: With continued success of elective endovascular aneurysm repair (EVAR), the procedure has now been
extended to ruptured aortas. The purpose of this study is to evaluate our results of ruptured abdominal aortic
aneurysms (AAA) and to determine if EVAR is equivalent to open surgery.
Methods: We retrospectively reviewed the results of all patients presenting to our main campus who underwent
repair of ruptured infrarenal AAAs between January 1990 to May 2008. Reoperative AAA surgery, juxtarenal
AAA and thoraco abdominal aortic aneurysms were excluded. Co-morbidities, intra-operative details, and post
operative complications were tabulated. EVAR and open repair were compared and survival analyzed by Kaplan
Meier models with Cox proportional hazards used to distinguish the risk between factor levels.
Results: One hundred and sixty patients had repair of a ruptured infrarenal AAA over this time period. Thirty two
of the 160 (20%) were repaired using EVAR. One hundred and twelve were considered free rupture (70%) and 48
contained rupture (30%). The average age was 72.6+9. The average APACHE score was 13.3+6.7. Intraoperative
mortality was 5.6%, with no patient undergoing EVAR suffering an intraoperative death. However, 30 day/ in-
hospital mortality was 31.9% with no significant difference between EVAR and open surgery (p=.93). There was
also no difference in ICU length of stay 12+16; p=.94, and hospital length of stay 19+12;p=.62 between the two
groups. Univariable analysis found that male gender (p=.02), and DM (p=.01), and tobacco use (p=.04) use were
associated with a higher intraoperative mortality. Multivariable analysis for 30day/in-hospital mortality found that
preoperative renal insufficiency OR 2.4(1.1,5.3; p=.04), preoperative hypotension OR 2.4(1.1,5.3;p=.02), and
preoperative cardiac arrest 3.8 (1.1,11.6;p=.03) were all associated with the greatest mortality.
Conclusions: Mortality rates for ruptured infrarenal AAA remain high. The use of EVAR for these procedures
now equals that for standard open repair with regard to 30day/in-hospital mortality, and is now a viable option.
Nevertheless, clinical judgment on when to use this as a primary repair modality must be exercised
Supported by T-35 Grant
74