Association of an endovascular-first protocol for ruptured abdominal aortic aneurysms with survival and discharge disposition

Brant W. Ullery, Kenneth Tran, Venita Chandra, Matthew Mell, Edmund J. Harris, Ronald L. Dalman, Jason T. Lee

Research output: Contribution to journalArticle

14 Citations (Scopus)

Abstract

IMPORTANCE Mortality after an open surgical repair of a ruptured abdominal aortic aneurysm (rAAA) remains high. The role and clinical benefit of ruptured endovascular aneurysm repair (rEVAR) have yet to be fully elucidated. OBJECTIVE To evaluate the effect of an endovascular-first protocol for patients with an rAAA on perioperative mortality and associated early clinical outcomes. DESIGN, SETTING, AND PARTICIPANTS Retrospective review of a consecutive series of patients presenting with an rAAA before (1997-2006) and after (2007-2014) implementation of an endovascular-first treatment strategy (ie, protocol) at an academic medical center. MAIN OUTCOMES AND MEASURES Early mortality, perioperative morbidity, discharge disposition, and overall survival. RESULTS A total of 88 patients with an rAAA were included in the analysis, including 46 patients in the preprotocol group (87.0% underwent an open repair and 13.0% underwent an rEVAR) and 42 patients in the intention-to-treat postprotocol group (33.3% underwent an open repair and 66.7% underwent an rEVAR; P = .001). Baseline demographics were similar between groups. Postprotocol patients died significantly less often at 30 days (14.3% vs 32.6%; P = .03), had a decreased incidence of major complications (45.0% vs 71.8%; P = .02), and had a greater likelihood of discharge to home (69.2% vs 42.1%; P = .04) after rAAA repair compared with preprotocol patients. Kaplan-Meier analysis demonstrated significantly greater long-term survival in the postprotocol period (log-rank P = .002). One-, 3-, and 5-year survival rates were 50.0%, 45.7%, and 39.1% for open repair, respectively, and 61.9%, 42.9%, and 23.8% for rEVAR, respectively. CONCLUSIONS AND RELEVANCE Implementation of a contemporary endovascular-first protocol for the treatment of an rAAA is associated with decreased perioperative morbidity and mortality, a higher likelihood of discharge to home, and improved long-term survival. Patients with an rAAA and appropriate anatomy should be offered endovascular repair as first-line treatment at experienced vascular centers.

Original languageEnglish (US)
Pages (from-to)1058-1065
Number of pages8
JournalJAMA Surgery
Volume150
Issue number11
DOIs
StatePublished - Jan 1 2015
Externally publishedYes

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Aortic Rupture
Abdominal Aortic Aneurysm
Ruptured Aneurysm
Survival
Mortality
Morbidity
Kaplan-Meier Estimate
Clinical Protocols
Blood Vessels
Anatomy
Survival Rate
Demography
Incidence
Therapeutics

ASJC Scopus subject areas

  • Surgery

Cite this

Association of an endovascular-first protocol for ruptured abdominal aortic aneurysms with survival and discharge disposition. / Ullery, Brant W.; Tran, Kenneth; Chandra, Venita; Mell, Matthew; Harris, Edmund J.; Dalman, Ronald L.; Lee, Jason T.

In: JAMA Surgery, Vol. 150, No. 11, 01.01.2015, p. 1058-1065.

Research output: Contribution to journalArticle

Ullery, Brant W. ; Tran, Kenneth ; Chandra, Venita ; Mell, Matthew ; Harris, Edmund J. ; Dalman, Ronald L. ; Lee, Jason T. / Association of an endovascular-first protocol for ruptured abdominal aortic aneurysms with survival and discharge disposition. In: JAMA Surgery. 2015 ; Vol. 150, No. 11. pp. 1058-1065.
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abstract = "IMPORTANCE Mortality after an open surgical repair of a ruptured abdominal aortic aneurysm (rAAA) remains high. The role and clinical benefit of ruptured endovascular aneurysm repair (rEVAR) have yet to be fully elucidated. OBJECTIVE To evaluate the effect of an endovascular-first protocol for patients with an rAAA on perioperative mortality and associated early clinical outcomes. DESIGN, SETTING, AND PARTICIPANTS Retrospective review of a consecutive series of patients presenting with an rAAA before (1997-2006) and after (2007-2014) implementation of an endovascular-first treatment strategy (ie, protocol) at an academic medical center. MAIN OUTCOMES AND MEASURES Early mortality, perioperative morbidity, discharge disposition, and overall survival. RESULTS A total of 88 patients with an rAAA were included in the analysis, including 46 patients in the preprotocol group (87.0{\%} underwent an open repair and 13.0{\%} underwent an rEVAR) and 42 patients in the intention-to-treat postprotocol group (33.3{\%} underwent an open repair and 66.7{\%} underwent an rEVAR; P = .001). Baseline demographics were similar between groups. Postprotocol patients died significantly less often at 30 days (14.3{\%} vs 32.6{\%}; P = .03), had a decreased incidence of major complications (45.0{\%} vs 71.8{\%}; P = .02), and had a greater likelihood of discharge to home (69.2{\%} vs 42.1{\%}; P = .04) after rAAA repair compared with preprotocol patients. Kaplan-Meier analysis demonstrated significantly greater long-term survival in the postprotocol period (log-rank P = .002). One-, 3-, and 5-year survival rates were 50.0{\%}, 45.7{\%}, and 39.1{\%} for open repair, respectively, and 61.9{\%}, 42.9{\%}, and 23.8{\%} for rEVAR, respectively. CONCLUSIONS AND RELEVANCE Implementation of a contemporary endovascular-first protocol for the treatment of an rAAA is associated with decreased perioperative morbidity and mortality, a higher likelihood of discharge to home, and improved long-term survival. Patients with an rAAA and appropriate anatomy should be offered endovascular repair as first-line treatment at experienced vascular centers.",
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AU - Ullery, Brant W.

AU - Tran, Kenneth

AU - Chandra, Venita

AU - Mell, Matthew

AU - Harris, Edmund J.

AU - Dalman, Ronald L.

AU - Lee, Jason T.

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N2 - IMPORTANCE Mortality after an open surgical repair of a ruptured abdominal aortic aneurysm (rAAA) remains high. The role and clinical benefit of ruptured endovascular aneurysm repair (rEVAR) have yet to be fully elucidated. OBJECTIVE To evaluate the effect of an endovascular-first protocol for patients with an rAAA on perioperative mortality and associated early clinical outcomes. DESIGN, SETTING, AND PARTICIPANTS Retrospective review of a consecutive series of patients presenting with an rAAA before (1997-2006) and after (2007-2014) implementation of an endovascular-first treatment strategy (ie, protocol) at an academic medical center. MAIN OUTCOMES AND MEASURES Early mortality, perioperative morbidity, discharge disposition, and overall survival. RESULTS A total of 88 patients with an rAAA were included in the analysis, including 46 patients in the preprotocol group (87.0% underwent an open repair and 13.0% underwent an rEVAR) and 42 patients in the intention-to-treat postprotocol group (33.3% underwent an open repair and 66.7% underwent an rEVAR; P = .001). Baseline demographics were similar between groups. Postprotocol patients died significantly less often at 30 days (14.3% vs 32.6%; P = .03), had a decreased incidence of major complications (45.0% vs 71.8%; P = .02), and had a greater likelihood of discharge to home (69.2% vs 42.1%; P = .04) after rAAA repair compared with preprotocol patients. Kaplan-Meier analysis demonstrated significantly greater long-term survival in the postprotocol period (log-rank P = .002). One-, 3-, and 5-year survival rates were 50.0%, 45.7%, and 39.1% for open repair, respectively, and 61.9%, 42.9%, and 23.8% for rEVAR, respectively. CONCLUSIONS AND RELEVANCE Implementation of a contemporary endovascular-first protocol for the treatment of an rAAA is associated with decreased perioperative morbidity and mortality, a higher likelihood of discharge to home, and improved long-term survival. Patients with an rAAA and appropriate anatomy should be offered endovascular repair as first-line treatment at experienced vascular centers.

AB - IMPORTANCE Mortality after an open surgical repair of a ruptured abdominal aortic aneurysm (rAAA) remains high. The role and clinical benefit of ruptured endovascular aneurysm repair (rEVAR) have yet to be fully elucidated. OBJECTIVE To evaluate the effect of an endovascular-first protocol for patients with an rAAA on perioperative mortality and associated early clinical outcomes. DESIGN, SETTING, AND PARTICIPANTS Retrospective review of a consecutive series of patients presenting with an rAAA before (1997-2006) and after (2007-2014) implementation of an endovascular-first treatment strategy (ie, protocol) at an academic medical center. MAIN OUTCOMES AND MEASURES Early mortality, perioperative morbidity, discharge disposition, and overall survival. RESULTS A total of 88 patients with an rAAA were included in the analysis, including 46 patients in the preprotocol group (87.0% underwent an open repair and 13.0% underwent an rEVAR) and 42 patients in the intention-to-treat postprotocol group (33.3% underwent an open repair and 66.7% underwent an rEVAR; P = .001). Baseline demographics were similar between groups. Postprotocol patients died significantly less often at 30 days (14.3% vs 32.6%; P = .03), had a decreased incidence of major complications (45.0% vs 71.8%; P = .02), and had a greater likelihood of discharge to home (69.2% vs 42.1%; P = .04) after rAAA repair compared with preprotocol patients. Kaplan-Meier analysis demonstrated significantly greater long-term survival in the postprotocol period (log-rank P = .002). One-, 3-, and 5-year survival rates were 50.0%, 45.7%, and 39.1% for open repair, respectively, and 61.9%, 42.9%, and 23.8% for rEVAR, respectively. CONCLUSIONS AND RELEVANCE Implementation of a contemporary endovascular-first protocol for the treatment of an rAAA is associated with decreased perioperative morbidity and mortality, a higher likelihood of discharge to home, and improved long-term survival. Patients with an rAAA and appropriate anatomy should be offered endovascular repair as first-line treatment at experienced vascular centers.

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