Ruptured INfrarenal abdominal AneurySm: aortiC repair using the ENduranT Endograft. The R.IN.AS.C.ENT.E. Study

BACKGROUND: Ruptured abdominal aortic aneurysm (rAAA) represents a vascular surgical emergency with high mortality. Endovascular aneurysm repair (EVAR) using the bifurcated Endurant stent graft system is widely employed; however, data specifically addressing its performance in infrarenal rAAA remain limited. METHODS: We conducted a retrospective, multicenter study including 121 patients with confirmed infrarenal rAAA treated exclusively with bifurcated Endurant II or IIs (Medtronic Inc., Minneapolis, Minnesota) devices across 5 Italian tertiary vascular centers from January 2014 to October 2024. Primary endpoints were technical success and 30-day all-cause mortality. Secondary outcomes included long-term survival, incidence of endoleaks, and reintervention rates. Patients receiving alternative stent grafts or hybrid procedures were excluded to ensure cohort homogeneity. At a median follow-up of 33.6 months (interquartile range, 4.9-72.3), 5-year survival was 65.4%, freedom from any endoleak was 92.6%, and freedom from reintervention was 91.6%. Late type Ia endoleaks occurred in 2.5% of patients. CONCLUSIONS: In this large, strictly defined infrarenal rAAA cohort, bifurcated Endurant stent grafts demonstrated high technical success and favorable early and mid-term clinical outcomes, including in patients with hostile neck anatomy. Early identification and management of ACS and judicious use of AOBs may improve survival. These findings reinforce current EVAR-first guidelines and emphasize the importance of device-specific outcome assessment in emergent rAAA repair.Clinical ImpactThis multicenter study provides one of the largest device-specific evaluations of bifurcated Endurant stent grafts for infrarenal ruptured abdominal aortic aneurysms in a rigorously defined Italian cohort, demonstrating high technical success (96.7%) and low 30-day mortality (15.7%) despite a high prevalence of hostile neck anatomy (54.5%). Abdominal compartment syndrome and the use of an aortic occlusion balloon emerged as independent predictors of early mortality, highlighting the critical role of perioperative management. Mid-term outcomes were favorable, with a 5-year survival rate of 65.4%, a low incidence of type Ia endoleak (2.5%), and high freedom from reintervention (91.6%). Overall, these findings support the use of Endurant devices in emergent settings for anatomically suitable patients and reinforce EVAR-first strategies in the management of ruptured abdominal aortic aneurysms.