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Predictors of Mortality after Endovascular Repair of Ruptured Abdominal Aortic Aneurysms
Roberto Silingardi, Antonio Lauricella, Vascular Surgeon, Giuseppe Saitta, Vascular Surgeon, Stefano Gennai, Vascular Surgeon, Giovanni Coppi, Vascular Surgeon, Gioachino Coppi, Chief of Vascular Surgery Department.
Nuovo Ospedale Sant Agostino Estense, MODENA, Italy.
OBJECTIVES:
Endovascular repair of ruptured abdominal aortic aneurysms (rAAA) is an alternative to open surgical repair, with the potential to diminish the risk of perioperative complications. While many predictors of outcome have been identified, the role of the type of endograft device has not been investigated.
METHODS:
Over a 16-years period ending in January 2015, 142 patients with rAAA were treated with endovascular repair (EVAR) at a single institution. Patients were followed for a mean of 44 months after repair and perioperative and long-term outcome was assessed with respect to baseline characteristics and the type of endograft implanted; aortouniiliac (78 patients, 54.9%), modular with proximal fixation (35 patients, 24.6%), or non-proximally fixated (Endologix Powerlink or AFX) devices (Endologix, Irvine, CA). Univariate comparisons were performed with Fisher’s exact test and multivariable analyses were done using binary logistic regression.
RESULTS:
Patients were managed with a standardized interdisciplinary institutional protocol that included permissive hypotension. The 30-day mortality was 28.2% with a 1-year and 5-year survival rates of 52% and 23%, respectively by Kaplan-Meier analysis. Perioperative mortality was related to chronic renal insufficiency (OR 3.4, P=.006), chronic pulmonary disease (OR 2.4, P=.032), refractory hypotension <80mmHg despite fluid resuscitation (OR 4.6, P=.001), and the need for an aortic balloon for stabilization of blood pressure (OR 23.4, P<.001). The use of local anesthesia was protective (OR 0.38, P=.017). Long-term survival was dependent on age ≥85 (HR 2.0, P=.002), refractory hypotension (HR 1.9, P=.005), and the requirement for an aortic occlusion balloon (HR 4.6, P<.001). The use of an Endologix device was protective (HR 0.50, P=.020). In a multivariable analysis of long-term survival, the use of an Endologix device was protective, but this benefit was confined to patients without persistent hypotension at presentation (HR 0.30, P=.017).
CONCLUSIONS:
Baseline characteristics of patients undergoing EVAR for rAAA predict short and long-term survival, many related to the patient’s hemodynamic stability at presentation. The use of Endologix device was a significant predictor of survival, but this benefit was limited to those patients presenting without refractory hypotension.
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