At the 2019 Charing Cross Symposium (CX; 15–18 April, London, UK), Vincenzo Brizzi (Bordeaux, France) reported the 10-year results for late rupture after endovascular aneurysm repair (EVAR) at his centre (Groupe Hospitalier Pellegrin, Bordeaux, France). These showed that late rupture was a rare event—accounting for 15% of all ruptured aneurysms cases during the 10-year period—but indicated that there had been a slow increase in incidence to the extent that it had reached 28% by 2018.
Brizzi noted that the concern over the long-term results of EVAR was “clear”, commenting that the recent European Society for Vascular Surgery guidelines recommend operators take into a patient’s ability to comply with the frequent lifelong surveillance that is required with the endovascular procedure when reviewing potential treatment options. He added that part of this concern related to studies showing that “the risk of death from aneurysm rupture [following EVAR] is persistent over time”.
To further explore the long-term outcomes after EVAR, Brizzi and his colleagues performed a retrospective study of the incidence of patients presenting with late rupture after EVAR—defined as >30 days after the procedure, as confirmed by computed tomography (CT)—at their centre. Their aim, Brizzi commented, was to “report the incidence, identify the causes, and evaluate the management” of late rupture. He explained that in-hospital mortality rather than 30-day mortality was the primary endpoint because “we noticed that, sometimes, patients stay in the hospital for two or three months without ever leaving the hospital before dying” and, therefore, in-hospital mortality would give a “more precise idea” of the mortality related to late rupture than would 30-day mortality.
Of 140 cases of ruptured aneurysm that presented between 2009 and 2018 (the study period), 121 (15%) were identified as late ruptures after EVAR. The incidence, Brizzi observed, appeared to slowly increase over time—ranging from 0% in 2009 to 28% in 2018. He stated that although the presumption might be that the late ruptures related to early-generation devices, only one of the late ruptures were associated with such a device and most of the ruptures occurred in the last four or five years (when a newer-generation device would have been used). The mean time between the EVAR procedure and late rupture was 54 months (with a peak during the second after the procedure).
Sixty-six per cent of patients with late rupture post EVAR had a type 1 endoleak but Brizzi noted that determining whether this was a cause or an effect of aneurysm evolution was difficult to determine. Additionally, 33% of cases of late rupture were related to a “violation of instructions for use” (ranging from poor device selection to the patient having a short neck).
In terms of management, 14 patients received endovascular repair (12 with proximal or distal extension and two undergoing relining) and four underwent surgical repair (three partial expansions and one lumbar artery ligation). The in-hospital mortality rates for these patients were 28.5% and 50% respectively. These findings, Brizzi stated, indicated that “a new endovascular procedure is often possible” but “sometimes conversion is the only option”. Overall, in-hospital mortality was “still high” at 42.8%.
Summarising the findings, he said: “Late rupture after EVAR is a rare but an increasing complication. Respect of instructions for use at the time of index EVAR and lifelong tailored surveillance seems to be essential for long-term success.” He added that “tailored” surveillance was important because the first CT scan after EVAR could be used to identify those at high risk of rupture (<10mm proximal or distal sealing and/ or endoleak) and should receive more frequent surveillance. Thus those at lower risk for rupture could receive less frequent surveillance, reducing costs and the risks of complications related to radiation/contrast exposure.
