Original Article

Ruptured Abdominal Aortic Aneurysm Treatment in the Stent Graft Era

Vascular and Endovascular Surgery 1-6 ª The Author(s) 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1538574414561232 ves.sagepub.com

Ulus A. Tulga, Prof1, Kucukay Fahrettin, Assoc. Prof2, Simsek Erdal, MD1, Oktem Sarper, Assoc. Prof2, Mola Serkan, MD1, Ozdemir Mustafa, MD2, Saritas Ahmet, Assoc. Prof1, Vural Kerem, Assoc. Prof1, and Birincioglu Levent, Assoc. Prof1

Abstract Background: We aim to decrease mortality and morbidity by early diagnosis and endovascular aneurysm repair (EVAR) or by using open surgery. Methods: The patients who had underwent open surgery and EVAR with a diagnosis of ruptured abdominal aortic aneurysms were evaluated retrospectively. Patients with EVAR were separated as group I and the patients with surgical operations constituted group II. The risk factors, duration of the operation, blood product usage, drainage amounts, complications, mortality, and morbidity rates were evaluated. Results: The duration of the operation and the required blood and blood products were lower in group I (P < .05). There is no any significant difference between the groups in terms of mortality, complications, short-, and long-term results. Conclusion: We support the idea that better results can be obtained by showing regard to suitable patient, suitable clinical condition, and suitable anatomy together with the correct choice of operation type. Keywords ruptured abdominal aortic aneurysm, endovascular aneurysm repair, surgery, treatment

Introduction Abdominal aortic aneurysm (AAA) develops to 80% in between renal arteries and aortic bifurcation. Abdominal aortic aneurysm is usually defined as an external aortic diameter of 3 cm.1,2 The incidence of occurrence increases in correlation with age (>60 years), hypertension, smoking, and caucasian ethnicity.3 For each decade after 60 years of age, a prevalance of 2% to 4% is observed.4,5 It is seen 6 times more in men compared to women6,7 and also more in white-skinned people when compared to Afro-Americans.8 There can be achieved an important decrease in mortality and morbidity with medical treatments, surgical, and endovascular aneurysm repair (EVAR) right after early diagnosis. The United States Preventive Services recommended male smoker patients of 65 to 75 years of age be scanned by abdominal ultrasonography.3 If ruptured abdominal aortic aneurysm (rAAA) is not intervened at an early period, it continues with high mortality and morbidity. Although screening techniques are developed in today’s world, still, surgical mortality is at around 48.5%.9 In 1999, EVAR was begun to be used vastly in treatment of AAA after the validation by Food and Drug Administration. Although its usage in rAAA was not accepted at first,10 in 2001, the use of ruptured endovascular aneurysm repair (REVAR) became 5.9% and 18.9% in 2006.

One of the concerns that must be considered when treating rAAAs is, which method of treatment including EVAR or open surgery is the best approach in such condition. Also, patient selection criteria for both methods are still under debate. Standardized protocols or guidelines for the management of rAAAs are not established. In a recent meta-analysis including 59.941 patients (8201 patients with EVAR and 51.740 open repair patients for rAAA), it was stated that EVAR was associated with a significantly lower incidence of in-hospital mortality, significantly decreased risk of morbidity, and less requirements of intraoperative blood transfusion.11 Similarly, in a prospective trial including 283 patients with rAAA, it was concluded that EVAR reduced the 30-day mortality and improved long-term survival up to 5 years. However, whereas open survivors required few graft-

1 Department of Cardiovascular Surgery, Turkiye Yuksek Ihtisas Training and Research Hospital, Ankara, Turkey 2 Department of Radiology, Turkiye Yuksek Ihtisas Training and Research Hospital, Ankara, Turkey

Corresponding Author: Simsek Erdal, Department of Cardiovascular Surgery, Turkiye Yuksek Ihtisas Training and Research Hospital, Kızılay Street, Altindag˘, Ankara, Turkey. Email: [email protected]

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related interventions, up to 23% of patients with EVAR would require reintervention for endoleaks or graft migration.12 A recent multicenter randomized controlled trial showed that there were no significant differences in combined death and severe complications between EVAR and open surgery.13 In this study, our aim was to evaluate the differences between endovascular and open surgical methods in rAAA.

Methods Between the years 2006 to 2013, the patients who consulted to our center with rAAA diagnosis and who were applied REVAR and open surgery were evaluated retrospectively. The study was followed monocentrically having obtained approval from the Turkiye Yuksek Ihtisas Training and research hospital ethical committee (00840-21.01.2013).

Criteria

Table 1. Baseline Characteristics of Group I and Group II Patients. Group I (n ¼ 26)

Group II (n ¼ 36)

Age 70 + 12.6 72 + 8.2 Male, n 19 35 Female, n 7 1 Smoking 70.8% 63.6% Hypertension 95.8% 63.6% Diabetes mellitus 54.2% 0% Atherosclerosis 87.5% 27.3% Hyperlipidemia 87.5% 36.4% A family history of aneurysm 79.2% 9.1% Before the procedure, maximum 72.2 + 23.3 72.5 + 18.5 aneurysm diameter, mm 1 year after aneurysm diameter, 54 + 19.2 35 + 7.8 mm In final examinations aneurysm 54.18 + 19.4 36.6 + 10.4 diameter, mm

P Value >.05 .05 >.05

hypertension, atherosclerosis, hyperlipidemia, and aneurysm history in the family were seen more in group I patients (P < .05). Although there was no significant difference in aneurysm diameters among the groups before the intervention, during the follow-up done after 1 year, the decrease in aneurysm diameters was found meaningful in favor of surgery. The grafts, operation periods, bleeding amounts, blood products used, stay-in durations, infection amounts, 30-day or 1-year mortality rates, and costs were compared in both the groups (Table 2). Operation periods, blood, and plasma transfusion amounts were found less in group I (P < .05). Cost rates, on the other hand, were lower in open surgery (P < .05). Although Y graft was used in 50% of open surgical group, Medtronic Talent (Ireland) and Medtronic Endurant (Ireland) bifurcated stent graft were used in all patients who underwent REVAR. There was no significant difference between the other parameters in Table 2. In all, 57.7% of patients from the REVAR group and 55.6% from the surgical group were discharged with full recovery (P > .05). In all, 38.5% of the discharged patients alive today constituted group I and 50% constituted group II (P > .05). There was no significant difference between the groups when compared in terms of complications (infection, respiratory problem, acute renal insufficiency, mesenteric ischemia, refemoral exploration, and the necessity of second intervention; Table 2). There was no significant difference between 30-day and 1-year mortalities. It was stated that 2 of the patients who underwent open surgery and had a long-term follow-up (myocardial infarction and multiple sclerosis) and 4 of the patients who underwent REVAR died due to reasons other than aneurysm (Alzheimer disease and myocardial infarction). Only 1 patient in the REVAR group died because of aneurysm 2 years after the operation.

Intervention time is first and foremost determined by the diameter of aneurysm and the extension speed. This intervention can be done surgically or by EVAR. It is still open to discussion when and how to intervene which patient in elective aneurysms. However, the necessity to, somehow, intervene all rAAAs is inevitable. Although 50% of rAAAs cannot reach the hospital, 50% of the patients who reach the hospital die without being intervened.16 Of the patients who came to our center, 4 died before any intervention could be done and those were excluded from the study. Early diagnosis by scanning should be made for this disease which progresses to mortality and morbidity. According to The American College of Cardiology/American Heart Association1 and The United States Preventive Services Task Force’s consensus,17 each male smoker patient between the age of 65 and 75 years should be scanned with ultrasonography. This way, there can be achieved an important decrease with early interventions both surgically and by EVAR after early diagnosis. Various complications can develop during both REVAR and open surgery. In a randomized study, the complications and rates for REVAR and open surgery are as follows18: severe cardiac complications: 7% (REVAR) and 3% (open surgery); renal insufficiency, moderate or severe: 11% and 31%; severe bowel ischemia: 4% and 8%; acute reoperation: 23% and 20%; stroke: none and 3%; graft infection with graft removal: none and none; severe graft occlusion: none and 2%; major amputation: none and 5%; spinal cord ischemia: 2% and none; endoleak: 42% in REVAR. Moderate and severe complications were found as 77% for REVAR and 80% for open surgery.19 Although renal insufficiency was found less in patients who underwent REVAR right after the operation, meaningful difference in terms of other complications was not found.18 The rates of shift to open surgery from REVAR in the course of operation were found as 14% in a randomized study and 4% to 6% in observational studies.20,21 Compartment syndrome, usually confronted during open surgery, was observed in 18% of the 40 patients who underwent REVAR, and among them a mortality rate of 57% was detected.22 Decompression was required in a situation where compartment syndrome developed as a result of leakage in undrained retroperitoneal hematoma or patent lumbar arteries.23 Acute complications (vessel damage, insufficient fixation, vein lumen occlusion, stent frame fractures, graft material separation, and fracture) and long-term complications (graft migration, endoleak, thrombosis, rupture, and new initiative) of EVAR may develop.

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Myocardial infarction and arrhythmia may develop at a rate of 2% to 6%24 and prosthetic graft infection may develop at a rate of 1% to 4%25 and this rate may be 2% after elective surgery, although 20% renal insufficiency may occur in rAAA surgery.24 Ischemic colitis can be observed as another important complication due to insufficient nutrition of rectosigmoid colon by collaterals. Throughout our study, there was no meaningful statistical difference observed between the 2 groups for complications mentioned in Table 2 except for numeral inequalities. Acute renal insufficiency was 7.7% in group I and 13.9% in group II; also, while respiratory problems were not observed in group I, it was 11.1% in group II. Despite these rates, there was no statistically meaningful difference detected. The numeral inequalities in respiratory problems showed the importance of EVAR for the patients with lung problems. The 30-day mortality after elective surgery can change from 2.7% to 5.8% depending on the number of cases in the hospital and the surgeon’s experience.25 The early period mortality and morbidity of elective EVAR application was found 1.6% to 4.8% better compared to surgery.26 Mortality rate was 55% in rAAA intervention in the centers which had just started EVAR, whereas this rate was 21% in open surgery.27 According to REVAR results, 30-day mortality was 18%,21 31%,28 31.7%,29 and 53%19 and cardiovascular occurrence was 5%,22 while the mortality rate in open surgery was 50%,28 53%,19 40.7%.29,30 When EVAR was performed in symptomatic but unruptured patients as a result of elective aneurysms and surgery was compared, there was no difference in the 30-day mortality.31 In our study, 30-day mortality was 42.3% for group I and 44.4% for group II and 1-year mortality was 7.7% 5.6%, respectively. Although the general condition of applied patients was often bad, our mortality rates are compatible with the literature. Regardless of the duration of hospital stay, the cost of operation was in favor of EVAR32 in our study, but in another study, it was shown that EVAR is more expensive than open surgery besides its advantages.32 Although there was no difference in terms of hospital stay in our study, surgical group was found to be more advantageous in terms of cost issues. Although REVAR’s superiority over open surgery is still not shown properly, REVAR can be applied to every patient who is anatomically eligible in the centers that provide open surgery and under emergency conditions.23 Among the advantages of EVAR, shorter period of hospital stay, earlier recovery of basal function capacity of the patient, less use of blood, and local application when necessary were regarded during the study. However, EVAR’s superiority over surgery in 1 to 2 years was not shown.33 In rAAA, all these situations mentioned earlier are important in defining the intervention type. The most essential factor affecting the decision of open surgery or EVAR is the clinical condition of the patient at the time. Generally, EVAR is performed inpatients whose general conditions are more stable and who are well limited by rupture that is not in shock status. Although we have more time to decide on the type of

intervention in a well-limited aneurysm, we have restricted time in patients who have low hypotensive and hematocrit in shock status. Success of REVAR is affected by factors depending on the patient, technical support, use of equipment, and surgeon’s experience. It is obvious that a surgeon having experience in cases with uncomplicated aneurysm will be more effective in applying REVAR. The patients who underwent REVAR were risky and complicated patients who could not be intervened in other centers and who were about to have cardiac arrest during their transfer and application to the hospital. In spite of all these negations, it is hopeful to have mortality and morbidity rates conforming with the literature.

Conclusion Although random patient choice can be done in intervention to elective aneurysm, in rAAA, suitable patient choice may be necessary for REVAR. Surgeons should decide and intervene considering their experience, the center they work for, and their patients. At this point, it will be more correct to each patient should be evaluated individually and be applied the most suitable treatment method rather than comparing the 2 methods.

The Limitations of Study Although there were numeral differences detected between the groups in terms of hospital stay periods, renal insufficiency, and respiratory problems, those were not found to be statistically significant differences in case of mortality. The study is designed as retrospective and the number of patients who were included in the study were not enough to make absolute conclusion. We believe that synergy should be highlighted more instead of comparing the 2 methods. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.

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Ruptured abdominal aortic aneurysm treatment in the stent graft era.

We aim to decrease mortality and morbidity by early diagnosis and endovascular aneurysm repair (EVAR) or by using open surgery...
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