rAAAs: EVAR associated with reduced mortality

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The World Registry has concluded that endovascular aneurysm repair (EVAR) results in better outcomes than open repair for ruptured abdominal aortic aneurysms (rAAAs)

During the recent Ajaccio Workshop, Dr Frank Veith, New York, presented an interesting summary of the results from the World Registry on rAAAs. The Registry gathered information on 583 patients who presented with rAAAs (excluded acute or symptomatic AAAs) from 43 centers. The results revealed that there was a 19% (113 patients) 30-day mortality rate.

According to Veith, such a low mortality rate (19%) and the fact that 10-15% of the cases were inoperable and were subsequently treated endovascularly suggests endovascular aneurysm repair (EVAR) is a better way to treat rAAAs, and are better than two randomised studies that did not show EVAR was better than open repair (Peppelenbosch, Buth et al J Vasc Surg 43:1111, 2006 and Hinchliffe, et al Eur J Vasc Endov Surg 32:506, 2006).

According to Veith, these differences in outcomes are due to management strategies, adjuncts and technical factors that facilitate EVAR treatment of rAAAs and make a difference in explaining the variable results of EVAR for rAAAs.

Veith explained that “when treating rAAAs the belief that there is a requirement for rapid control and mandatory laparotomy, this is just not so.” The solution is to restrict resuscitation and use what Veith calls “hypotensive haemostasis”. When hypotensive haemostasis does not work the operator should employ a supraceliac balloon via femoral access. He added that the balloon technique was easier and quicker, although the “blowdown” of the balloon as the blood pressurecomes back up can be a problem. This is prevented by leaving the large sheath in place to support the balloon..

Somewhat controversially, he said that computed tomography (CT) was not necessary as an angiogram was sufficient. He cited data from the World Registry that showed only three centers (of 43 centres) did not perform CT on all patients before undertaking EVAR for rAAAs, and many did it only on stable patients. This was because some patients have died during CT and the biggest gain from EVAR was with the poorest risk unstable patients.

Conclusion

In conclusion, Veith said that it is not just technical tips that improve outcomes, but having a defined system is in place for these cases. He underscored the importance of planning, preparing, setting up equipment and rehearsing the plan for dealing with these patients.