P-016 - THE MAJORITY OF PATIENTS WITH A RUPTURED ABDOMINAL AORTIC ANEURYSM ARE NOT ANATOMICALLY SUITABLE FOR ENDOVASCULAR ANEURYSM REPAIR

TOPIC:
Abdominal Aortic Aneurysms
AUTHORS:
Gjosha B. (Department of Surgery, Amphia Hospital ~ Breda ~ Netherlands) , Boer G.J. (Department of Vascular Surgery, Maasstad Hospital ~ Rotterdam ~ Netherlands) , Fioole B. (Department of Vascular Surgery, Maasstad Hospital ~ Rotterdam ~ Netherlands) , Buimer M.G. (Department of Surgery, Amphia Hospital ~ Breda ~ Netherlands) , De Bruin J.L. (Department of Vascular Surgery, Erasmus University Medical Center ~ Rotterdam ~ Netherlands) , Suman A. (Amphia Academy, Amphia Hospital ~ Breda ~ Netherlands) , Van Der Laan L. (Department of Surgery, Amphia Hospital ~ Breda ~ Netherlands)
Introduction:
The adoption of endovascular aneurysm repair (EVAR) for ruptured abdominal aortic aneurysms (RAAA) has increased over time with an improved relative survival benefit compared to open surgical repair (OSR).(1) Suitability for EVAR is determined by the aortic morphology and the stent-graft instructions for use (IFU). Previous studies report an anatomical suitability of 39 - 64% in RAAA patients.(2-7) No recent observational studies report the anatomical suitability after treatment allocation; EVAR or OSR. The acute setting of a RAAA is paired with time-constraints, situational pressure and dependent on the local set-up of the hospital, theoretically affecting the surgeon's anatomical assessment. Moreover, in patients with a life-threatening RAAA the IFU will not always be followed. This study aimed to objectify the accuracy of preoperative morphology assessment when deciding between OSR or EVAR in patients with a RAAA and ascertain EVAR suitability in relation to the IFU.
Methods:
Patients with surgical repair of RAAA in two Dutch institutions from January 2014 to December 2019 were retrospectively assessed for anatomical suitability using their preoperative computed tomography angiography (CTA). Three-dimensional reconstruction and central luminal line (CLL) installment were used. Anatomical suitability was defined according to the IFU of the used stent-graft system.
Results:
Out of 128 included patients, 88% was male and the mean age was 74.1 (±7.6 SD). 31 patients (24%) had anatomy inside the IFU criteria. 94 (73%) were treated with OSR and 34 (27%) were treated with EVAR. 16% of OSR patients and 47% of EVAR patients had anatomy inside the IFU for EVAR. 37% of EVAR eligible patients (i.e. anatomy inside the IFU and hemodynamic stability) had not received EVAR, which was 7% (n=7) of the OSR treated patients. In patients with anatomy outside the IFU, 90% had unsuitable neck anatomy, of which 71% had insufficient neck length. 27% had at least one unsuitable distal landing zone. Perioperative mortality was 26.6%, with no difference between OSR and EVAR (26.6% versus 26.5%, p = .989).
Conclusion:
The majority of RAAA patients do not have aortic anatomy inside the IFU for EVAR, mostly due to insufficient neck length. Retrospective anatomical assessment in this current real-life cohort demonstrates that triaging RAAA patients in an EVAR-first strategy is adequate, but EVAR application could be improved as more than a third of EVAR eligible patients underwent OSR. However, whether anatomy outside the IFU equates to unsuitability for EVAR remains a matter of debate.
References:
1. Varkevisser RRB, Swerdlow NJ, de Guerre LEVM, Dansey K, Stangenberg L, Giles KA, et al. Five-year survival following endovascular repair of ruptured abdominal aortic aneurysms is improving. J Vasc Surg 2020;72(1):105-113.e4. 2. Powell JT, Sweeting MJ, Thompson MM, Ashleigh R, Bell R, Gomes M, et al. Endovascular or open repair strategy for ruptured abdominal aortic aneurysm: 30 day outcomes from IMPROVE randomised trial. BMJ 2014;348. 3. Reimerink JJ, Hoornweg LL, Vahl AC, Wisselink W, van den Broek TAA, Legemate DA, et al. Endovascular repair versus open repair of ruptured abdominal aortic aneurysms: a multicenter randomized controlled trial. Ann Surg 2013;258(2):248-56. 4. Hoornweg LL, Wisselink W, Vahl A, Balm R. The Amsterdam Acute Aneurysm Trial: suitability and application rate for endovascular repair of ruptured abdominal aortic aneurysms. Eur J Vasc Endovasc Surg 2007;33(6):679-83. 5. Slater BJ, Harris EJ, Lee JT. Anatomic suitability of ruptured abdominal aortic aneurysms for endovascular repair. Ann Vasc Surg 2008;22(6):716-22. 6. Dick F, Diehm N, Opfermann P, von Allmen R, Tevaearai H, Schmidli J. Endovascular suitability and outcome after open surgery for ruptured abdominal aortic aneurysm. Br J Surg 2012;99(7):940-7. 7. Powell JT, Sweeting MJ, Thompson MM, Hinchliffe RJ, Ashleigh R, Bell R, et al. The effect of aortic morphology on peri-operative mortality of ruptured abdominal aortic aneurysm. Eur Heart J 2015;36(21):1328-34.
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