Paul J Speicher1, Andrew S Barbas1, Leila Mureebe2. 1. Department of Surgery, Duke University Medical Center, Durham, NC. 2. Department of Surgery, Duke University Medical Center, Durham, NC. Electronic address: leila.mureebe@duke.edu.
Abstract
BACKGROUND: Management of ruptured abdominal aortic aneurysms (rAAA) remains one of the most challenging situations in vascular surgery. The aim of our study was to examine national trends and compare contemporary outcomes of open and endovascular repair (EVAR) for rAAA across a wide spectrum of hospitals in the United States. METHODS: Data from the 2005 to 2011 National Surgical Quality Improvement Project (NSQIP) Participant User File were used to identify patients with rAAA undergoing open or EVAR for this analysis. The primary outcome measures for our analysis were 30-day postoperative mortality, operative mortality, 30-day overall complication rate, and early return to the operating room. A nonparsimonious multiple logistic regression model was constructed to adjust for patient- and procedure-related confounding factors. As confirmatory analysis to address concerns of selection bias, we also conducted a separate propensity-matched analysis of the study cohort. RESULTS: A total of 1,997 patients were identified who underwent repair of ruptured or dissecting AAA and met study inclusion criteria. Of these, 1,383 (69.3%) patients underwent an open procedure and 614 (30.7%) patients underwent EVAR. After adjusting for potential confounders, open repair had 1.7 times higher odds (95% confidence interval [CI] 1.24-2.35, P=0.001) of all-cause 30-day mortality; 2.06 times higher odds (95% CI 1.23-3.46, P=0.006) of operative mortality, and 1.9 times higher odds (95% CI 1.41-2.55, P<0.001) of overall complications, compared with EVAR. CONCLUSIONS: EVAR is a safe and, in appropriately selected patients, superior approach to open surgery for the management of patients with rAAA. On multivariate analysis, patients who underwent open repair were at significantly increased risk of morbidity and mortality. In clinical settings where adequate resources, personnel, and surgical expertise are present, an endovascular approach should be strongly considered for all patients with acceptable anatomy.
BACKGROUND: Management of ruptured abdominal aortic aneurysms (rAAA) remains one of the most challenging situations in vascular surgery. The aim of our study was to examine national trends and compare contemporary outcomes of open and endovascular repair (EVAR) for rAAA across a wide spectrum of hospitals in the United States. METHODS: Data from the 2005 to 2011 National Surgical Quality Improvement Project (NSQIP) Participant User File were used to identify patients with rAAA undergoing open or EVAR for this analysis. The primary outcome measures for our analysis were 30-day postoperative mortality, operative mortality, 30-day overall complication rate, and early return to the operating room. A nonparsimonious multiple logistic regression model was constructed to adjust for patient- and procedure-related confounding factors. As confirmatory analysis to address concerns of selection bias, we also conducted a separate propensity-matched analysis of the study cohort. RESULTS: A total of 1,997 patients were identified who underwent repair of ruptured or dissecting AAA and met study inclusion criteria. Of these, 1,383 (69.3%) patients underwent an open procedure and 614 (30.7%) patients underwent EVAR. After adjusting for potential confounders, open repair had 1.7 times higher odds (95% confidence interval [CI] 1.24-2.35, P=0.001) of all-cause 30-day mortality; 2.06 times higher odds (95% CI 1.23-3.46, P=0.006) of operative mortality, and 1.9 times higher odds (95% CI 1.41-2.55, P<0.001) of overall complications, compared with EVAR. CONCLUSIONS: EVAR is a safe and, in appropriately selected patients, superior approach to open surgery for the management of patients with rAAA. On multivariate analysis, patients who underwent open repair were at significantly increased risk of morbidity and mortality. In clinical settings where adequate resources, personnel, and surgical expertise are present, an endovascular approach should be strongly considered for all patients with acceptable anatomy.