PMID- 18346575
OWN - NLM
STAT- MEDLINE
DCOM- 20080725
LR  - 20080318
IS  - 0890-5096 (Print)
IS  - 0890-5096 (Linking)
VI  - 22
IP  - 2
DP  - 2008 Mar
TI  - Is there a selection bias in applying endovascular aneurysm repair for rupture?
PG  - 215-20
LID - 10.1016/j.avsg.2007.12.006 [doi]
AB  - Accumulating data suggest that endovascular repair (EVAR) of ruptured abdominal 
      aortic aneurysms (RAAAs) leads to reduced mortality, but concern exists that this 
      may reflect selection bias. We reviewed our overall rupture experience early 
      after our protocol was instituted to explore this question. We instituted a 
      defined protocol for RAAA with emphasis on EVAR in July 2002, which included 
      device availability (consignment), preoperative training, 24-hr access to our 
      surgical endosuite and ability to operate imaging in an emergency, and immediate 
      availability of a transbrachial balloon cutdown cart for all cases. Charts of all 
      RAAA patients who arrived in the operating room alive since institution of our 
      protocol were reviewed. Computed tomographic (CT) scans were re-reviewed to 
      assess potentially suitable anatomic candidates. From July 2002 to May 2006, a 
      total of 52 RAAAs were treated at our institution: 15 pararenal RAAAs, all 
      treated by open repair (PR-OPEN), and 37 infrarenal RAAAs, 20 treated by open 
      repair (IR-OPEN) and 17 treated by EVAR (IR-EVAR, 32% of all ruptures). Mortality 
      rates in the three groups were 47%, 75%, and 35% (p < 0.02 vs. IR-OPEN), 
      respectively. Although mortality was significantly lower in the EVAR group, 
      overall mortality was 53% (28/52). On re-review of the operative notes and CT 
      scans, it is estimated that more than half of those cases repaired using open 
      techniques could have been repaired using EVAR based on anatomic criteria alone. 
      The most common reason for open repair was hemodynamic instability 
      preoperatively; only a minority of cases were excluded from EVAR based on 
      unfavorable anatomy after CT scan review in the emergency room. In conclusion, 
      during our early experience EVAR for rupture was associated with significantly 
      reduced mortality. However, our overall mortality was no different from 
      historical values, and this fact along with the extremely high mortality seen in 
      the IR-OPEN group suggest that we are simply selecting patients with the greatest 
      chance of survival to undergo EVAR. It also appears that many patients who are 
      anatomically suitable for EVAR are undergoing open operation because of 
      hemodynamic instability. If EVAR for rupture truly decreases mortality in all 
      patients, a much more aggressive attitude toward EVAR may be required to lower 
      the overall mortality rate.
FAU - Lee, Richard W
AU  - Lee RW
AD  - Division of Vascular Surgery, Department of Surgery, University of Rochester 
      Medical Center, Rochester, NY 14642, USA.
FAU - Rhodes, Jeffery M
AU  - Rhodes JM
FAU - Singh, Michael J
AU  - Singh MJ
FAU - Davies, Mark G
AU  - Davies MG
FAU - Wolford, Heather Y
AU  - Wolford HY
FAU - Diachun, Carol
AU  - Diachun C
FAU - Norton, Russell
AU  - Norton R
FAU - Illig, Karl A
AU  - Illig KA
LA  - eng
PT  - Journal Article
PL  - Netherlands
TA  - Ann Vasc Surg
JT  - Annals of vascular surgery
JID - 8703941
SB  - IM
MH  - Aortic Aneurysm, Abdominal/*surgery
MH  - Aortic Rupture/*surgery
MH  - *Blood Vessel Prosthesis Implantation
MH  - Female
MH  - Humans
MH  - Male
MH  - *Patient Selection
MH  - Selection Bias
EDAT- 2008/03/19 09:00
MHDA- 2008/07/26 09:00
CRDT- 2008/03/19 09:00
PHST- 2007/03/05 00:00 [received]
PHST- 2007/10/01 00:00 [revised]
PHST- 2007/12/04 00:00 [accepted]
PHST- 2008/03/19 09:00 [pubmed]
PHST- 2008/07/26 09:00 [medline]
PHST- 2008/03/19 09:00 [entrez]
AID - S0890-5096(08)00009-5 [pii]
AID - 10.1016/j.avsg.2007.12.006 [doi]
PST - ppublish
SO  - Ann Vasc Surg. 2008 Mar;22(2):215-20. doi: 10.1016/j.avsg.2007.12.006.