Offering Options for Aneurysm Repair Leads to Reduction in Mortality

By Charles Bankhead
VIENNA, Austria, 22 june 2008 -- Deaths from ruptured abdominal aortic aneurysm decreased significantly when patients could choose between endovascular or open surgery, results of a small retrospective study showed.
The overall reduction in postoperative mortality included a 50% decrease in 90-day mortality, Harald Teufelsbauer, M.D., of the Medical University of Vienna, and colleagues reported in the June issue of Archives of Surgery.
Older patients had a threefold reduction in mortality, and the mortality risk of open surgery also declined significantly.
"Hemodynamically stable and older patients seem to benefit the most from this new, less-invasive technique, thereby improving the overall results of emergency aneurysm treatment," the authors said.
If an abdominal aortic aneurysm ruptures, 70% to 80% of patients die before reaching a hospital. As many as half of the survivors die after open surgery, resulting in an overall mortality of 80% to 90%.
Using endovascular repair as an elective treatment has led to a reduction in hospital mortality, the authors said. In particular, older patients and those with significant comorbidities have benefited from the less invasive treatment option.
To add to the evidence on endovascular repair, Dr. Teufelsbauer and colleagues retrospectively reviewed records on consecutive patients who underwent abdominal aortic aneurysm repair from October 1999 through July 2006.
The review period was separated into two 41-month timespans. During the first period, 42 patients were treated exclusively by open graft repair. The option of endovascular repair became available at the start of the second 41-month period, during which 31 patients had open procedures and 16 underwent endovascular repair.
During the second period, the endovascular group was significantly older (76 versus 69, P=0.01) but had a significantly lower percentage of hemodynamically unstable patients (12.5% versus 54.84%, P=0.006). Otherwise, the two groups did not differ demographically or by preoperative risk. The median age of patients treated during the first period was 73.4.
The overall 90-day mortality decreased from 54.8% during the first 41 months to 27.7% during the second period (P<0.01).
Among hemodynamically stable patients, mortality decreased from 40% to 10.7% after the introduction of endovascular treatment (P<0.02), but mortality among unstable patients did not change (68.2% versus 52.6%).
Mortality associated with open graft repair also decreased -- from 54.8% during the first 41 months to 29% during the second (P<0.03).
Introduction of the endovascular option led to lower 90-day mortality for all age groups, but particularly in the oldest patients:
<68, 35.71% versus 12.5%
68-75.5, 50% versus 41.18%
>75.5, 75% versus 28.57% (P<0.01)
"The [open] surgical technique . . . has remained nearly unchanged during the last five decades," the authors said. "With the introduction of [endovascular treatment] . . . superior early postoperative survival rates, especially in patients with considerable preoperative risk profiles, could be achieved."
"Thus, it is reasonable to assume that the use of [endovascular repair] in patients with ruptured abdominal aortic aneurysm may also ameliorate treatment results."
However, the question of whether endovascular treatment is superior to open surgery has yet to be addressed in a large, randomized clinical trial, they added.
In an invited critique, William Pevec, M.D., of the University of California Davis, credited the authors with a "well-written review" but added, "There is not much new here."
He also noted that of the patients who underwent endovascular repair, 38% needed additional surgery for abdominal compartment syndrome or revision of the endograft.
And the apparent decrease in mortality between study periods in those undergoing open repair may be a result of removal of the older patients from the cohort, or it could simply be an artifact based on the small sample size, Dr. Pevec said.
"Based on this experience," he said, "one can conclude that endovascular repair is a good option in stable patients with [ruptured abdominal aortic aneurysm] but even with this less-invasive procedure, [it] is still related to significant complications and long lengths of hospital stay."
The authors reported no disclosures. Dr. Pevec reported no disclosures.
Primary source: Archives of SurgerySource reference:Wibmer A, et al "Improved survival after abdominal aortic aneurysm rupture by offering both open and endovascular repair" Arch Surg 2008; 143: 544-549. Additional source: Archives of SurgerySource reference: Pevec WC "Invited critique" Arch Surg 2008; 143:550.