Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University Hospital, Örebro, Sweden.
Department of Cardiothoracic and Vascular Surgery, Linköping University Hospital, Linköping, Sweden.
J Vasc Surg. 2023 Mar;77(3):741-749. doi: 10.1016/j.jvs.2022.10.032. Epub 2022 Oct 28.
Endovascular aneurysm repair (EVAR) has been increasingly performed for ruptured abdominal aortic aneurysms (rAAAs). However, multiple randomized trials have failed to demonstrate a survival benefit compared with open aortic surgery. During a 12-year period, 100% of patients without a history of aneurysm surgery had undergone EVAR for a rAAA at Örebro University Hospital, with no emergent open aortic surgery performed. In the present study, we evaluated the mortality and technical success during this "EVAR-only" period.
A single-center, retrospective observational study was conducted. We identified all patients who had presented to Örebro University Hospital with a rAAA between October 2009 and September 2021. Patients with isolated iliac artery, thoracic, and thoracoabdominal aortic ruptures were not included. Patients who had received previous aortic interventions (open or endovascular) and patients who had received palliative treatment instead of surgical intervention were also excluded. The patient characteristics, perioperative and postoperative data, and mortality rate were investigated.
EVAR had been performed in 100 patients. Preoperative hemodynamic instability had been present in 54 patients (54%), and 18 (18%) had undergone aortic balloon occlusion. The aneurysm location was infrarenal in 89 patients (89%). Bifurcated stent grafts had been used in 97 patients (97%), and adjunct endovascular techniques had been used for 27 patients (27%). Of 98 patients, EVAR had been performed with the patient under local anesthesia for 62 patients (63%). Peri- and postoperative complications at 30 days had occurred in 20 of 100 patients (20%) and 22 of 79 patients (28%), respectively. The overall mortality at 30 days was 27% (27 of 100 patients), and the mortality for those with an isolated infrarenal rAAA was 24% (21 of 89 patients). The overall mortality at 1 year was 39% (39 of 100 patients) and for those with an isolated infrarenal rAAA was 37% (33 of 89 patients). The presence of preoperative hemodynamic instability and the use of ABO were statistically significantly and independently associated with increased 30-day mortality on multivariate logistic regression analysis.
All 100 patients who had undergone surgery for a rAAA had been treated using EVAR and endovascular adjuncts, with a relatively low mortality rate, thus continuing the "EVAR-only" approach. A low proportion of rAAA patients were considered surgically unsuitable. These findings support the applicability of EVAR for the treatment of all rAAAs at suitable centers.
血管内动脉瘤修复术（EVAR）已越来越多地用于治疗破裂的腹主动脉瘤（rAAA）。然而，多项随机试验未能证明与开放主动脉手术相比具有生存优势。在 12 年期间，奥雷布洛大学医院对所有无动脉瘤手术史的 rAAA 患者均行 EVAR 治疗，未行紧急开放主动脉手术。在本研究中，我们评估了在此“仅行 EVAR”期间的死亡率和技术成功率。
这是一项单中心回顾性观察性研究。我们确定了 2009 年 10 月至 2021 年 9 月期间在奥雷布洛大学医院就诊的所有 rAAA 患者。不包括孤立的髂动脉、胸主动脉和胸腹主动脉破裂的患者。排除了既往接受过主动脉介入治疗（开放或血管内）和接受姑息治疗而不是手术干预的患者。研究了患者特征、围手术期和术后数据以及死亡率。
100 例患者行 EVAR 治疗。54 例（54%）患者术前存在血流动力学不稳定，18 例（18%）行主动脉球囊阻断。89 例（89%）患者的动脉瘤位于肾下。97 例（97%）患者使用分叉支架移植物，27 例（27%）患者使用辅助血管内技术。98 例患者中，62 例（63%）在局部麻醉下进行 EVAR。100 例患者中，围手术期 30 天内发生并发症的患者有 20 例（20%），79 例中有 22 例（28%）。30 天总死亡率为 27%（100 例患者中有 27 例），孤立肾下 rAAA 的死亡率为 24%（89 例患者中有 21 例）。1 年总死亡率为 39%（100 例患者中有 39 例），孤立肾下 rAAA 的死亡率为 37%（89 例患者中有 33 例）。多变量逻辑回归分析显示，术前血流动力学不稳定和 ABO 的存在与 30 天死亡率增加具有统计学显著和独立的相关性。
所有接受 rAAA 手术的 100 例患者均采用 EVAR 和血管内辅助治疗，死亡率相对较低，因此继续采用“仅行 EVAR”的方法。很少有 rAAA 患者被认为不适合手术治疗。这些发现支持在合适的中心应用 EVAR 治疗所有 rAAA。
