Comparison of Open and Endovascular Repair of Ruptured Abdominal Aortic Aneurysms From the ACS-NSQIP 2005–07

PURPOSE: To compare endovascular (EVAR) and open surgical repair (OSR) for ruptured abdominal aortic aneurysms (RAAA) in terms of preoperative hemodynamic status and comorbidities. METHODS: The 2005 to 2007 American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was interrogated to find all patients undergoing repair for RAAA. Of the 567 RAAA repairs identified, 121 (21%) were endovascular and 446 (79%) were open. Demographics, comorbidities, and preoperative hemodynamic status were compared by repair method. RESULTS: Age, sex, and race were similar between repair cohorts. EVAR patients had greater incidences of recent myocardial infarction (7% versus 2%, p<0.05), revascularization or amputation for peripheral vascular disease (8% versus 3%, p<0.05), and cerebrovascular disease (22% versus 11%, p<0.01). Preoperative hemodynamic status was similar based on need for >4 units of blood (3% versus 6%, p = 0.31), intubation (12% versus 17%, p = 0.18), impaired sensorium (7% versus 11%, p = 0.25), coma (4% versus 5%, p = 0.65), acute renal failure (2% versus 2%, p = 0.60), and ASA class 5 (29% versus 34%, p = 0.29). Open repair was associated with greater operative time (3.3 versus 2.6 hours, p<0.01) and intraoperative blood transfusions (8 versus 2 units, p<0.001). Overall mortality was 33.5% (EVAR 24% versus OSR 36%; OR 1.8, 95% CI 1.1 to 2.8, p<0.05). After adjusting for preoperative comorbidities and all preoperative hemodynamic variables, mortality after open repair was greater than after EVAR (OR 1.9, 95% CI 1.1 to 3.2, p<0.05). Overall postoperative complications were greater after open repair (62% versus 47%, p<0.01). Graft failure requiring reintervention was higher after EVAR (4% versus 1%, p<0.05), while rates of return to the operating room for a major operation were similar (21% versus 24%, p = 0.43). CONCLUSION: For RAAA within NSQIP hospitals in recent years, preoperative hemodynamic status was similar between EVAR and OSR, but EVAR patients had greater comorbidities. Despite this and after accounting for minor differences in hemodynamic status, EVAR mortality was lower than OSR mortality. Institutions with adequate experience and resources should attempt endovascular repair for RAAA when anatomy allows.