Endovascular repair of ruptured abdominal aortic aneurysms is superior to open repair in risk stratified patients: a look at the United States experience through the SVS Vascular Quality Initiative 2003 2013 William P. Robinson III, MD, FACS Assistant Professor of Surgery Division of Vascular and Endovascular Surgery University of Massachusetts Medical School Worcester, Massachusetts
Disclosure Speaker name: William P. Robinson, MD... I have the following potential conflicts of interest to report: Consulting Employment in industry Stockholder of a healthcare company Owner of a healthcare company Other(s) x I do not have any potential conflict of interest
Background Retrospective single center studies report reduced mortality and morbidity after endovascular repair (EVAR) of ruptured abdominal aortic aneurysm (RAAA) Limited by selection bias Randomized control trials have shown no benefit to EVAR over open repair (OR) for RAAA Limited by high crossover rate and stable patients Unknown whether EVAR is superior to OR for RAAA
Background Comparisons of EVAR vs. OR not stratified by validated measures of preoperative risk Vascular Study Group of New England (VSGNE) RAAA risk scoring system accurately predicts mortality after OR of RAAA (Robinson et al, J Vasc Surg 2013;57:354-61)
Background VSGNE RAAA risk scoring system assigns patients to strata of operative risk based on most powerful predictors of mortality Variable OR Integer Weight Age > 76 5.3 2 Cardiac Arrest 4.3 2 Loss of Consciousness 2.6 1 Suprarenal Clamp 2.4 1 VSGNE RAAA Risk Score: 0-6
Objectives Compare in-hospital mortality, major morbidity and length of stay after EVAR and OR of RAAA in patients stratified by validated measure of preoperative risk
Hypothesis EVAR is associated with lower in-hospital mortality, major morbidity and length of stay than OR across strata of preoperative risk defined by VSGNE RAAA risk score
Methods Vascular Quality Initiative (VQI) database All RAAA patients undergoing EVAR or OR between years 2003 to 2013 VSGNE RAAA risk scoring system validated in VQI cohort c-statistic =.78; Hosmer-Lemeshow test, p= 0.29 Patients stratified by VSGNE RAAA risk score Low (score 0-1) Medium (score 2-3) High (score 4-6)
Methods Primary Endpoint: In-hospital mortality Secondary Endpoints Major Morbidity Cardiac and respiratory complications Renal insufficiency Leg and bowel ischemia Length of Stay (LOS) Intensive care unit (ICU) Hospital
Results: Patients 1282 patients underwent repair of RAAA in VQI EVAR: 590 patients OR: 692 patients Stratification using VSGNE RAAA Risk Score 117 patients excluded EVAR: 514 patients OR: 651 patients Low risk (VSGNE 0-1) 282 Medium risk 212 High risk 20 Low risk 344 Medium risk 245 High risk 62
Results: Baseline Patient Characteristics
Results: Baseline Patient Characteristics
Results: Operative Characteristics
Results: In-Hospital Mortality Overall In-Hospital Mortality: EVAR 25% vs. OR 33% (n=126) (n=218) P =.001
Results: Risk-Stratified Mortality
Results: In-Hospital Major Morbidity EVAR has lower overall in-hospital major morbidity
Results: Risk Stratified Morbidity In low and medium risk patients, EVAR has lower inhospital major morbidity In high risk patients, EVAR has lower respiratory complications
Results: LOS in Survivors EVAR has lower ICU and hospital LOS among survivors
Results: Risk Stratified LOS In low and medium risk patients, EVAR has lower ICU and hospital LOS
Conclusions In this risk stratified comparison using a national clinical database, EVAR of RAAA has lower in-hospital mortality than OR except in patients of highest mortality risk EVAR has lower in-hospital major morbidity compared to OR in patients in all risk strata For RAAA patients at highest preoperative risk, there is no difference in mortality between EVAR and OR
Conclusions EVAR confers lower overall mortality and should be utilized to treat RAAA patients when anatomically feasible EVAR should not be expected to reduce mortality in RAAA patients at the highest preoperative risk
Thank you
Endovascular repair of ruptured abdominal aortic aneurysms is superior to open repair in risk stratified patients: a look at the United States experience through the SVS Vascular Quality Initiative 2003 2013 William P. Robinson III, MD, FACS Assistant Professor of Surgery Division of Vascular and Endovascular Surgery University of Massachusetts Medical School Worcester, Massachusetts