Favorable discharge disposition and survival after successful endovascular repair of ruptured abdominal aortic aneurysm

Objective: Endovascular repair of ruptured abdominal aortic aneurysm (rEVAR) has been shown to improve perioperative outcomes compared with open surgical repair (OSR). Follow-up of these patients, however, is lacking. In this study, we compare the discharge disposition and midterm survival of ruptured aneurysm patients who survived treatment with either rEVAR or OSR.

Methods: We performed an institutional review board-approved, single-institution, retrospective review of all patients with ruptured abdominal aortic aneurysms (rAAAs) admitted from July 2007 to February 2012. Primary outcomes were discharge disposition and midterm survival (>30 days after the index operation). We also evaluated compliance with follow-up and prevalence of endoleak.

Results: A total of 118 patients were analyzed. Eight patients received only comfort care, 10 died in the operating room, 39 underwent OSR, and 61 had rEVAR. Average age and sex were similar (OSR, 77 ± 7.8 years, 85% male; rEVAR, 74 ± 7.4 years, 79% male). Seventy-two survived to discharge (54% OSR [21/39]; 84% rEVAR [51/61]; P = .001). OSR patients had longer lengths of intensive care unit and total length of stay than rEVAR (11.8 ± 10.4/23 ± 16.4 days vs 6.3 ± 8.5/12.3 ± 13.0 days; P = .002/.02). Only 19% (4/21) of patients were discharged home after OSR, rather than to a skilled nursing facility. Significantly more rEVAR patients were discharged to home rather than a skilled nursing facility (65%; 33/51) (P = .0004). Overall, the follow-up rate for determination of survival for patients who lived past 30 days was 86% (56/65; median, 14 months; 25th-75th interquartile, 3.1-27.8). Multivariable logistic regression revealed only the type of procedure performed and perioperative hypotension predicted discharge destination. Kaplan-Meier analysis revealed a significant midterm survival benefit for patients after rEVAR compared with OSR (P = .01, log-rank). Subgroup analysis of survivors past 30 days revealed similar rates of midterm survival (P = .7, log-rank). Overall, midterm relative risk reduction for death after rEVAR vs OSR was 35% (95% confidence interval, 0.06-0.59).

Conclusions: We have previously demonstrated that successful utilization of rEVAR improves the early survival of rAAA patients compared with OSR. This study shows that more patients are able to be discharged to home after rEVAR and that the early survival advantage is continued in midterm follow-up, suggesting that rEVAR should be attempted first when feasible. Further studies are needed to determine the long-term durability of endovascular repair in the management of rAAA as well as the impact on cost and long-term quality of life.