In patients with ruptured abdominal aortic aneurysm does endovascular repair improve 30-day mortality?

Endovascular aneurysm repair (EVAR) has become widely adopted as the primary treatment modality for abdominal aortic aneurysm in the elective setting. However, equipoise exists regarding the use of this technology for acute ruptured aneurysms. A best evidence topic in cardiovascular surgery was written according to a structured protocol. The question addressed, whether a policy for endovascular repair as the primary mode of treatment for ruptured abdominal aortic aneurysms (rAAAs) would improve outcomes. One thousand three hundred and twenty-eight papers were found using the reported search; of these, 24 presented represent the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studies, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. The majority of data available derives from level 2b evidence, with only a single level 1b and no level 1a studies available. Appraisal of theses studies is constrained by limited patient numbers, selection bias and heterogeneity in treatment protocols between the reported series. The sole prospective randomised controlled trial comparing open and endovascular treatments found a 53% mortality amongst patients treated by either modality. This study was, however, underpowered and contrary to numerous cohort series that show reduced mortality with EVAR. The largest body of evidence is found in a co-operative multicentre cohort study spanning 49 institutions that showed superiority of EVAR over open repair in terms of 30-day mortality. We conclude that, within the limitations of the published literature to date, endovascular repair as the primary treatment for rAAA is achievable and appears to be associated with favourable mortality over open repair with appropriate case selection.