Post on 10-Mar-2021
Endovascular treatment for ruptured abdominal aortic aneurysm(review)
Dillon, M. (Author), Cardwell, C. (Author), Blair, P. (Author), Ellis, P. (Author), Kee, F. (Author), & Harkin, D.(Author). (2007). Endovascular treatment for ruptured abdominal aortic aneurysm (review). Web publication/site,Unknown Publisher.
Queen's University Belfast - Research Portal:Link to publication record in Queen's University Belfast Research Portal
General rightsCopyright for the publications made accessible via the Queen's University Belfast Research Portal is retained by the author(s) and / or othercopyright owners and it is a condition of accessing these publications that users recognise and abide by the legal requirements associatedwith these rights.
Take down policyThe Research Portal is Queen's institutional repository that provides access to Queen's research output. Every effort has been made toensure that content in the Research Portal does not infringe any person's rights, or applicable UK laws. If you discover content in theResearch Portal that you believe breaches copyright or violates any law, please contact openaccess@qub.ac.uk.
Download date:10. Aug. 2021
Endovascular treatment for ruptured abdominal aortic
aneurysm (Review)
Dillon M, Cardwell C, Blair PH, Ellis P, Kee F, Harkin DW
This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library2007, Issue 1
http://www.thecochranelibrary.com
1Endovascular treatment for ruptured abdominal aortic aneurysm (Review)
Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
T A B L E O F C O N T E N T S
1ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4CRITERIA FOR CONSIDERING STUDIES FOR THIS REVIEW . . . . . . . . . . . . . . . . . .
4SEARCH METHODS FOR IDENTIFICATION OF STUDIES . . . . . . . . . . . . . . . . . . .
4METHODS OF THE REVIEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4DESCRIPTION OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5METHODOLOGICAL QUALITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7POTENTIAL CONFLICT OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . .
7ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11Characteristics of excluded studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
12ADDITIONAL TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
12Table 01. Search strategy used to search CENTRAL . . . . . . . . . . . . . . . . . . . . . . .
12Table 02. Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
13Table 03. Length of ICU stay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
13Table 04. Length of Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
14Table 05. Blood loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
14Table 06. Transfusion requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . .
14GRAPHS AND OTHER TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
14COVER SHEET . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
iEndovascular treatment for ruptured abdominal aortic aneurysm (Review)
Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Endovascular treatment for ruptured abdominal aorticaneurysm (Review)
Dillon M, Cardwell C, Blair PH, Ellis P, Kee F, Harkin DW
Status: New
This record should be cited as:
Dillon M, Cardwell C, Blair PH, Ellis P, Kee F, Harkin DW. Endovascular treatment for ruptured abdominal aortic aneurysm. CochraneDatabase of Systematic Reviews 2007, Issue 1. Art. No.: CD005261. DOI: 10.1002/14651858.CD005261.pub2.
This version first published online: 24 January 2007 in Issue 1, 2007.
Date of most recent substantive amendment: 01 November 2006
A B S T R A C T
Background
An abdominal aortic aneurysm (AAA) (the pathological enlargement of the aorta) can develop in both men and women as they grow
older. It is most commonly seen in men over the age of 65 years. Progressive aneurysm enlargement can lead to rupture and massive
internal bleeding, a fatal event unless timely repair can be achieved. Despite improvements in perioperative care, mortality remains
high (approximately 50%) after conventional open surgical repair. A newer minimally invasive technique, endovascular repair, has
been shown to reduce early morbidity and mortality, as compared to conventional open surgery, for planned AAA repair. Emergency
endovascular repair (eEVAR) has been used successfully to treat ruptured abdominal aortic aneurysm (RAAA), proving that it is feasible
in selected patients. However, it is not yet known if eEVAR will lead to significant improvements in outcomes for these patients or
indeed if it can replace conventional open repair as the preferred treatment for this lethal condition.
Objectives
To compare the advantages and disadvantages of eEVAR in comparison with conventional open surgical repair for the treatment of
RAAA.
Search strategy
The Cochrane Peripheral Vascular Diseases Group searched their trials register (last searched October 2006) and the Cochrane Central
Register of Controlled Trials (CENTRAL) database (last searched Issue 4, 2006). We searched a number of electronic databases and
handsearched relevant journals until March 2006 to identify studies for inclusion.
Selection criteria
Randomised controlled trials in which patients with a confirmed ruptured abdominal aortic aneurysm were randomly allocated to
eEVAR, or conventional open surgical repair.
Data collection and analysis
Studies identified for potential inclusion were independently assessed for eligibility by at least two reviewers, with excluded studies
further checked by the agreed arbitrators. As no randomised controlled trials were identified at present no tests of heterogeneity or
sensitivity analysis were performed.
Main results
There were no randomised controlled trials identified at present comparing eEVAR with conventional open surgical repair for the
treatment of RAAA.
Authors’ conclusions
There is no high quality evidence to support the use of eEVAR in the treatment of RAAA. However, evidence from prospective
controlled studies without randomisation, prospective studies, and retrospective case series suggest that eEVAR is feasible in selected
1Endovascular treatment for ruptured abdominal aortic aneurysm (Review)
Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
patients, with outcomes comparable to best conventional open surgical repair for the treatment of RAAA . Furthermore, endovascular
repair in selected patients may be associated with a trend towards reductions in blood loss, duration of intensive care treatment, and
mortality.
P L A I N L A N G U A G E S U M M A R Y
Endovascular repair for ruptured abdominal aortic aneurysm
The abdominal aorta is the main artery supplying blood to the lower part of the body. An abnormal ballooning and weakening of
the wall of the aorta (aortic aneurysm) particularly affects men as they grow older. An aneurysm may progressively enlarge without
obvious symptoms yet it is potentially lethal as the aneurysm can burst (rupture) causing massive internal bleeding. Death is inevitable
unless the bleeding can be stopped and blood flow to the lower body restored promptly. Until recently this required an open operation
(laparotomy) to clamp the abdominal aorta and replace the segment of the aorta with a synthetic artery tube-graft. Many patients do not
survive this major operation due to the effects of massive bleeding or failure of vital organs, such as the heart, lungs, and kidneys despite
improvements in surgical technique and care of the critically ill patient. A recent minimally invasive technique, termed endovascular
repair, allows the surgeon to pass a stent graft through the blood vessels from the groin to the site of rupture where it is positioned,
attached to healthy artery above and below the aneurysm to stop bleeding and form a new channel for blood flow. This technique is
successful in suitable patients for the planned treatment of non-ruptured aneurysms and can reduce early post-operative complications
and deaths. The present review looked at the available evidence for its effectiveness compared with open surgery for ruptured aneurysms.
The review authors searched the medical literature but found no completed randomised controlled trial. Evidence from case series, 10
prospective and 21 retrospective reports, indicates that emergency endovascular repair is feasible and may reduce blood loss, duration
of stay in intensive care and deaths in selected patients. These reports were from vascular surgery centres with considerable experience
of the technique.
B A C K G R O U N D
Abdominal aortic aneurysm (AAA), the pathological enlargement
of the main artery in the abdomen, affects between 1.2% and
7.6% of the population over 50 years of age in the United King-
dom. The prevalence of AAA in men is approximately three times
greater than in women, and the incidence increases with advancing
age (Scott 1991; Scott 1995). The cause of AAA is unknown but
its development is associated with many of the cardiovascular risk
factors that predispose to atherosclerosis and arterial occlusive dis-
ease, perhaps most importantly tobacco smoking (Lederle 1997;
Wilmink 1999). Genetic factors are also important, as the risk of
aneurysm development is significantly greater in relatives of those
with a diagnosed AAA (Powell 2003; van Vlijmen 2002). Unfortu-
nately, many aneurysms progressively enlarge without overt symp-
toms, presenting only when the aneurysm ruptures, a catastrophic
event causing massive internal bleeding that results in death in
the majority of those affected. Recent randomised controlled tri-
als have shown that mortality can be reduced by mass popula-
tion ultrasound screening in men, with early detection and inter-
vention preventing future rupture and aneurysm-related mortality
(Ashton 2002; Norman 2004). The risk of aneurysm rupture has
been shown to be proportional to aneurysm size, with aneurysms
measuring less than 5.4 cm having an annual rupture rate of ap-
proximately 1% whereas those greater than 7.0 cm in diameter
have an annual rupture rate of 32.5% (Gorham 2004). The UK
Small Aneurysm Trial has shown that in general, patients benefit
from aneurysm repair when maximum aneurysm diameter exceeds
5.5 cm, at which stage the risk of spontaneous rupture exceeds
the risks of conventional open surgical repair (Greenhalgh 1998).
Currently, rupture leads to death in over 80% of those affected,
including 30% to 65% of those who receive conventional open
surgical repair (Gorham 2004; Veith 2003), and is responsible for
over 6800 deaths per annum in the United Kingdom and 2.1% of
all deaths in men over 65 years (Ashton 2002; Scott 1991). These
findings contrast with the significantly better outcome if conven-
tional open surgical repair of the AAA is planned before rupture
can occur.
Historically, conventional open surgical repair was the only effec-
tive treatment for AAA, involving open surgical exposure of the
aorta, and replacement of the aneurysm with a synthetic tube-
graft. This complex major operation carries a significant morbid-
ity and mortality, due to the combined effects of surgical expo-
sure, haemorrhage, and aortic clamping with related lower torso
ischaemia-reperfusion injury. However, with improvements in pa-
tient selection and perioperative care excellent results can now be
achieved with open repair, with some specialist centres reporting
mortality rates of less than 2% and surgeons in non-specialist units
achieving mortality rates of 5% to 8% (Gorham 2004; Green-
halgh 1998; Veith 2003). However, in the last two decades this
approach to treatment of patients with AAA has been challenged
2Endovascular treatment for ruptured abdominal aortic aneurysm (Review)
Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
by the arrival of a new minimally-invasive technique, endovascular
aneurysm repair (EVAR). The EVAR technique was first reported
by Parodi in 1991 (Parodi 1991). He described the placement of
a home-made, material-covered metal stent across an abdominal
aneurysm to exclude this from the circulation and to form a new
channel for blood flow. The stent is delivered to the aorta from
a remote accessible vessel such as the femoral artery at the groin.
Since this seminal report, outcomes have progressively improved
with significant advancements in commercial stent design, deliv-
ery, and implantation technique (Harris 2005; Thomas 2005),
making this a valuable alternative to open repair in selected suitable
cases (Lee 2004). Modern aortic stent grafts are available in a range
of sizes and can be custom designed. The addition of fenestrations
and side-branches can adapt the stent to suit difficult anatomi-
cal variations encountered. These modular devices are most com-
monly delivered remotely by open exposure of the femoral arter-
ies, although percutaneous access is possible and are broadly de-
scribed as, the aorto-uni-iliac graft (single-lumen) and aorto-bi-
iliac (bifurcated-lumen) graft. The minimally invasive nature of
this technique allows it to be performed under regional or even lo-
cal anaesthesia, rather than general anaesthesia. This increases the
availability of this technique to those patients with significant con-
comitant medical disease who may otherwise have been consid-
ered unfit for surgery (Lachat 2002; Veith 2003). Two recent large
prospective randomised controlled trials have compared EVAR
with conventional open repair for the treatment of large abdom-
inal aortic aneurysms, and have shown significant reductions in
early complications and mortality (EVAR 2004; Prinssen 2004).
However, whilst endovascular repair for un-ruptured abdominal
aortic aneurysm clearly has a role in “healthy” patients, these trials
have also reinforced the knowledge that open repair is a success-
ful technique and will remain a common form of treatment for
over half of those patients presenting with a large abdominal aortic
aneurysm for whom EVAR is unsuitable on anatomical grounds
or due to other factors (EVAR 2004; EVAR 2005). Furthermore,
it is now clear that those patients who are unfit for open surgical
repair can expect such a high mortality rate from their co-mor-
bid disease, that even successful EVAR of their aneurysm is un-
likely to alter overall prognosis and life expectancy, which remains
guarded (EVAR2 2005). It is also clear from these studies that
EVAR is associated with a higher re-intervention rate than open
repair (EVAR 2004; EVAR 2005), and registry data would suggest
that these re-intervention rates can remain constant and may even
increase with time (Harris 2005; Thomas 2005). As such long-
term surveillance is essential after EVAR to monitor for endoleaks
and stent integrity in order to reduce the small but significant in-
cidence of late aneurysm rupture.
Rupture of an Abdominal Aortic Aneurysm (AAA) is a catastrophic
event which is occurring with increasing frequency in our increas-
ingly elderly population. Despite improved surgical techniques
and advances in intensive care support, ruptured AAA (RAAA)
continues to confer overall a 35% to 70% mortality (Adam 1999;
Huber 1995). The rupture of an AAA exposes the patients to the
combined injury of a period of haemorrhagic shock and lower
torso ischaemia followed by a reperfusion injury on successful
revascularisation. This ’two hit’ mechanism of injury, initiates a
systemic inflammatory response syndrome (SIRS) (Lindsay 1999),
characterized by increased microvascular permeability and neu-
trophil sequestration, leading to a multiple organ dysfunction syn-
drome (MODS), the primary cause of 70% of such deaths and a
contributory cause of the remainder (Bown 2003; Harris 1991).
Haemorrhagic shock occurs due to an acute loss of circulating
blood volume resulting in a period of prolonged hypotension and
the resultant decreased perfusion of the tissues leads to tissue in-
jury (Roumen 1993). Disruption of the blood supply to the lower
limbs, during rupture and surgical repair induces a lower torso
tissue ischaemia. Restoration of the blood supply to the temporar-
ily ischaemic tissue gives rise to the ischaemia-reperfusion injury.
These combined injuries activate multiple inflammatory pathways
in the body inducing a harmful proliferative systemic inflamma-
tory response syndrome characterized by immune cells activation,
pro-inflammatory mediator production and widespread vital or-
gan injury (heart, lungs, liver, kidney, gut, etc.). The sequential fail-
ure of these organs despite intensive care support, once established
leads to death in over 70% of cases (Bown 2003; Roumen 1993).
The high mortality associated with open repair has led many to
look for alternative treatments for the management of RAAA. Sev-
eral studies have confirmed that the use of EVAR, especially un-
der local anaesthesia, reduces the physiological insult to the body
as compared to conventional open surgical repair (Cuypers 2001;
Peppelenbosch 2003). Emergency endovascular aneurysm repair
(eEVAR) has been successfully carried out using a variety of proto-
cols and techniques and would appear to offer a feasible alternative
to conventional open repair in selected patients (Peppelenbosch
2003; van Sambeek 2002). These early reports have suggested a
trend toward reduction in perioperative morbidity and mortality
in selected patients.
The EVAR technique has been successfully used in the planned
treatment of non-ruptured aneurysms of the abdominal aorta and
when compared to conventional open surgical repair, has been
shown to reduce early post-operative complications and death. In
this review we have assessed the available evidence to support the
use of eEVAR to treat ruptured abdominal aortic aneurysm.
O B J E C T I V E S
This review will draw together available trial evidence to allow
assessment of the advantages and disadvantages of EVAR for pa-
tients with RAAA (eEVAR). This will be determined by the effect
on short-term mortality, major complication rates, aneurysm ex-
clusion, and late complications when compared with patients who
have had conventional open repair of RAAA.
3Endovascular treatment for ruptured abdominal aortic aneurysm (Review)
Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
C R I T E R I A F O R C O N S I D E R I N G
S T U D I E S F O R T H I S R E V I E W
Types of studies
Prospective randomised controlled trials (RCTs) comparing eE-
VAR with conventional open surgical repair.
Types of participants
All patients in whom a ruptured abdominal aortic aneurysm had
been diagnosed by computerised tomography (CT), angiography,
or magnetic resonance angiography (MRA) were considered for
inclusion. There must have been evidence of rupture on imaging or
objective acute symptoms suggestive of impending rupture of the
aneurysm (abdominal or back pain in a patient with an aneurysm)
to warrant inclusion.
We planned to perform sub-group analysis to evaluate the impact
of patients treated with aorto-uni-iliac devices and those treated
with aorto-bi-iliac devices.
Studies where objective evidence of RAAA is not clear were ex-
cluded.
Types of intervention
All types of endovascular device were considered in comparison
with conventional open surgical treatment for patients considered
fit for surgery.
Types of outcome measures
The following outcome measures were considered:
(1) short-term mortality (30 day, or in-hospital mortality, i.e. pro-
cedure related);
(2) aneurysm exclusion (no flow in the AAA sac, or further ex-
travasation (escape of blood from the vessel into the tissues) be-
yond the sac on follow-up imaging 30 days after the procedure);
(3) major complications for example, open conversion, haemor-
rhage, myocardial infarction, stroke, renal failure (20% rise in
creatinine levels), respiratory failure (need for post-operative me-
chanical ventilation), pneumonia, bowel ischaemia, lower limb is-
chaemia, etc;
(4) minor complications for example, catheter site haematoma,
wound infection, etc;
(5) long term complications and mortality; re-intervention rates
for problems related to the RAAA or its treatment will be sought
where possible, as will cause of death, with or without re-interven-
tion, i.e., device-related;
(6) quality of life, (standardised questionnaires);
(7) economic analysis (cost per patient).
S E A R C H M E T H O D S F O R
I D E N T I F I C A T I O N O F S T U D I E S
See: Cochrane Peripheral Vascular Diseases Group methods used
in reviews.
This review drew on the search strategy developed for the
Cochrane Peripheral Vascular Diseases (PVD) Group. The
Cochrane Peripheral Vascular Diseases Group searched their
trials register (last searched October 2006) and the Cochrane
Central Register of Controlled Trials (CENTRAL) database (last
searched Issue 4, 2006) for trials describing endovascular repair
of ruptured or symptomatic abdominal aortic aneurysm. For
search strategy used to search CENTRAL see Table 01.
We handsearched relevant surgical and interventional radiological
journals, and performed electronic searches of the following
bibliographic databases:
(1) AMED (Allied and Complementary Medicine Database);
(2) Best Evidence;
(3) Biological Abstracts
(4) HMIC (Health Management of Information Consortium -
comprising DH-data, the King’s Fund Database and Helmis);
(5) NHS DARE (Database of Assessments of Reviews of Effects);
(6) NHS EED (Economics Evaluations Database);
(7) NHS HTA (Health Technology Assessment);
(8) PubMed (last 180 days) ;
(9) Science Citation Index;
(10) MEDLINE .
Searches were not restricted by publication type, study design or
language of publication.
The initial use of methodological filters in electronic databases to
limit the search results to controlled trials and systematic reviews
was abandoned as it proved fruitless. The search terms were
widened using the keywords “endovascular ” AND “abdominal
aortic aneurysm” AND “ruptured” in all databases. The last
search prior to preparation of the first draft of this review was
performed in March 2006 and the PVD Group re-ran searches
of their trials register and CENTRAL in October 2006. No
additional trials were found.
M E T H O D S O F T H E R E V I E W
Selection and quality assessment of trials
MD
and DWH evaluated the trials under consideration independently
for appropriateness for inclusion and for methodological quality.
Disagreements were resolved on discussion with the review team
and agreed arbitrators.
D E S C R I P T I O N O F S T U D I E S
No randomised controlled trials comparing endovascular treat-
ment and open repair for ruptured abdominal aortic aneurysm
were identified. A number of case reviews comparing outcomes of
eEVAR for RAAA with open surgical repair were found and ex-
cluded due to lack of randomisation and in some cases the eEVAR
4Endovascular treatment for ruptured abdominal aortic aneurysm (Review)
Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
had been compared to historical controls (see Table of Excluded
Studies).
M E T H O D O L O G I C A L Q U A L I T Y
There are no included studies.
R E S U L T S
There are no completed randomised controlled trials comparing
eEVAR with conventional open surgical repair for the treatment of
RAAA. Seven case reports (Corso 2005; Hinchcliffe 2002; Kumar
2002; Morales 2005; Seelig 2000; Verhagen 2003; Yusuf 1994)
and thirty-one case series (21 retrospective and 10 prospective)
describing eEVAR were identified (see list of excluded studies).
D I S C U S S I O N
The extremely high mortality rate from RAAA is well recognised.
Detailed risk analysis and scoring systems have been shown to pre-
dict non-survivors in certain groups but individual patient out-
comes cannot be accurately predicted. Clinicians have been reti-
cent to apply these scoring systems rigidly as to do so would serve
to preclude most patients with RAAA from surgical repair, con-
demning them to certain death (Alsac 2005b; Korhonen 2004;
Neary 2003). It is also now clear that those patients who undergo
successful open repair of RAAA enjoy a post-operative quality of
life similar to the “normal population” (Hinterseher 2004; Tam-
byraja 2004)
Since the first description of the EVAR technique (Parodi 1991),
many specialised vascular surgery centres have adopted its use in
the elective treatment of abdominal aortic aneurysm, where its use
has contributed to a reduction in early postoperative morbidity
and mortality (EVAR 2004; Prinssen 2004). Many of these centres
have been integral to the clinical development of the techniques
and devices employed for endovascular repair and all reports on
eEVAR studies considered for this review are from centres with
considerable experience of elective EVAR.
Selection of cases on the basis of precise anatomical suitability for
elective EVAR has been shown to be associated with a much lower
rate of re-intervention and associated procedures, with consequent
reductions in morbidity and procedure-related cost. Most authors
have used established criteria derived from elective EVAR to de-
termine anatomical suitability for eEVAR. Evidence from several
studies has shown that the aneurysm morphology is significantly
more challenging for endovascular techniques in those assessed
for RAAA compared with those undergoing elective EVAR (Alsac
2005b; Hinchliffe 2003). However the excluded studies revealed
substantial variation in the inclusion and exclusion criteria em-
ployed, in particular many groups accept inferior proximal neck
anatomy which would preclude patients from elective EVAR, sug-
gesting a trend to be more inclusive in these high risk patients. This
would account for the wide range in the excluded studies, where
anywhere between 40% to 80% of RAAA were considered to be
anatomically suitable for eEVAR (Lee 2004;Lloyd 2004; Peppe-
lenbosch 2003; Reichart 2003; Wilson 2004). There is no long
term follow-up data available for patients undergoing eEVAR and
therefore, there is no evidence to suggest whether or not the relax-
ation of the criteria for anatomical suitability will lead to future
problems, such as increased rates of endoleak, graft displacement,
complications, re-interventions or the need for open conversion.
In the excluded studies, the majority of centres use contrast-en-
hanced computed tomographic angiography (CTA) to assess the
anatomical suitability of aneurysms for eEVAR. Other centres de-
scribe using intra-operative calibration angiography as an effective
alternative in order to reduce pre-operative delays. This has po-
tential disadvantages as it does not show the presence of atheroma
or thrombus at the proximal fixation site, which could make the
procedure technically more difficult and could adversely affect the
outcome of the procedure. Performing CTA, though more accu-
rate, can result in a procedural delay. A recent prospective study
of 100 patients with RAAA treated by open surgery demonstrated
no significant difference in outcome whether or not a pre-opera-
tive CT scan had been performed (Boyle 2005), suggesting such
delays may not be clinically important. Another study has shown
that the majority of patients with RAAA who are not operated
upon survive for more than two hours after hospital admission and
maintain a satisfactory systolic blood pressure greater than 80 mm
Hg with minimal fluid resuscitation (Lloyd 2004), which would
allow sufficient time for radiological assessment in most specialist
centres.
In the haemodynamically unstable patient with RAAA, rapid con-
trol of progressive haemorrhage at the aortic rupture site is of-
ten considered paramount. This may be achieved in conventional
open surgery by laparotomy and application of an aortic clamp
proximal to the aneurysm. In the setting of endovascular repair,
this control may be achieved endoluminally by the placement and
inflation of a balloon occlusion device in the aorta proximal to
the rupture site (often the supra-celiac aorta) or by swift endograft
placement and deployment. The excluded studies describe the
use of both aorto-uni-iliac (AUI) or aorto-bi-iliac (ABI) devices.
Aorto-uni-iliac devices have the advantage of ease in deployment
and therefore rapid control of haemorrhage is possible. As they are
not anatomical a surgical femoro-femoro crossover bypass graft is
required following graft deployment to provide blood flow to the
contralateral lower limb. Aorto-bi-iliac devices, or modular bifur-
cated grafts, give a better anatomical result without the need for
crossover bypass grafts, but often require more deployment time.
Many units now advocate a policy of permissive hypotension to
reduce bleeding and prevent re-bleeding from the contained aortic
rupture site. In general this policy is applied in the excluded stud-
ies, but there was wide variation in the lowest tolerated systolic
5Endovascular treatment for ruptured abdominal aortic aneurysm (Review)
Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
blood pressures (SBP). It is notable that even when SBP as low as
50 mm Hg were permitted, no increased incidence of end-organ
injury, such as visceral ischaemia, was reported (Scharrer-Pamler
2003).
Two recent large prospective randomised controlled trials have
compared EVAR with conventional open repair for the treat-
ment of large abdominal aortic aneurysms and have shown sig-
nificant reductions in early complications and mortality (EVAR
2004; Prinssen 2004). Paradoxically, recent data from the afore-
mentioned EVAR 1 Trial have shown that despite early advantages
in morbidity and mortality at one-year, mortality is not signifi-
cantly different between those randomised to EVAR compared to
open surgery and at an increased cost (EVAR 2005). Interestingly,
high-risk patients deemed unfit for elective open surgical repair,
faired no better with EVAR than with best medical management
in terms of aneurysm-related or all-cause mortality, suggesting that
unfitness for open surgery as judged in these studies may be an
indicator for reduced life-expectancy (EVAR2 2005). Notable also
from the EVAR 2 Trial is that the peri-procedural morality rate of
9% in these high-risk patients was significantly greater than their
lower risk counterparts in EVAR 1 Trial (EVAR 2004; EVAR2
2005). However, the risk / benefit analysis is different in patients
with RAAA as failure to treat means inevitable death and conven-
tional open surgery continues to carry a very significant risk of
mortality, 35% to 70%. Emergency endovascular repair (eEVAR)
is less invasive, reduces surgical stress, reduces haemodynamic in-
stability, and can be achieved with a local or loco-regional anaes-
thesia. In the excluded studies the reported reductions in mortality
rates with eEVAR, compared to contemporary or historical con-
trols undergoing open repair, mirrors a procedural-related reduc-
tion blood loss, transfusion requirements, and length of ICU stay
(see additional tables Table 02; Table 03; Table 04; Table 05; Table
06). These perceived benefits are generally attributed to a reduc-
tion in the physiological insult to the patients, as eEVAR obvi-
ates the need for laparotomy, exposure and handling of abdominal
contents, and aorto-iliac dissection and clamping. In the major-
ity of the excluded studies eEVAR was conducted under general
anaesthetic, although even AUI device placement with surgical
femoro-femoral bypass graft can be achieved under local anaes-
thetic regimes. However, as there were no randomised controlled
trials identified and few of the results from the excluded studies
reached a level of statistical significance, we are unable to draw
definite conclusions without further evidence.
A distinct learning curve effect is noted in the excluded studies
involving eEVAR. The more recent studies show a greater reduc-
tion in procedure times, mortality and complication rates. Earlier
reports included hand-made or hand-customized devices, whereas
more recent series make use of a range of commercial stent grafts
of modular design with size ranges designed to suit most conceiv-
able requirements. As has been seen with elective EVAR practice,
advancements in stent-graft design and endovascular techniques
have lead to improved outcomes (Harris 2005; Thomas 2005).
Re-intervention rates from the excluded studies appear compara-
ble with those seen with elective endovascular repair (EVAR 2004;
EVAR 2005; Harris 2005; Thomas 2005). Long-term data are
needed in order to truly assess if eEVAR is a durable treatment in
relation to rate of endoleak, maintenance of stent-graft integrity
and late rupture risk. It is clear that the introduction of an eEVAR
service has substantial cost implications, in terms of staff, fixed
resources and procedure-associated equipment. This may impact
on the transferability of this technique beyond specialist centres.
In order to provide a comprehensive 24-hour service the necessary
team of surgeons, radiologists, anaesthetists, radiographers, nurses
and technicians need to be available at all times. Furthermore, in
most excluded studies a wide range of stent-graft stock was avail-
able to cope with the variable anatomy encountered, which can
prove costly for a single institution unless a satisfactory arrange-
ment can be achieved with a commercial partner. These obvious re-
source implications are further compounded by the need for post-
operative follow up and imaging surveillance, as in elective setting.
The elective use of EVAR has shown the need for long-term post
procedure graft surveillance to confirm stent-graft integrity and
persistent aneurysm exclusion. Complications may require a high
rate of re-intervention by endovascular or open means, in relation
to endoleak, device migration, strut fracture, limb occlusion or
late rupture.
In the absence of randomised controlled trials, we are unable to
fully evaluate the role of emergency endovascular repair of rup-
tured abdominal aortic aneurysms (eEVAR). Early results from
specialist centres in the excluded studies show this technique is
feasible. Data suggesting reduced morbidity and mortality in se-
lected patients must be interpreted with caution due to the lack of
randomised controlled trials. The authors are concerned that there
may be ethical difficulties in designing a prospective randomised
controlled trial comparing eEVAR and conventional open repair
for RAAA given the lack of capacity for informed consent in many
of these patients and the growing body of literature which though
unrandomised, describes reductions in mortality and morbidity
following eEVAR.
A U T H O R S ’ C O N C L U S I O N S
Implications for practice
The benefit of endovascular repair for abdominal aortic aneurysm
rupture (eEVAR) has not been established as no randomised con-
trolled trials were found. The reductions in mortality rates, Inten-
sive Care Unit (ICU) stay and blood loss seen in the larger series
identified are encouraging and may suggest a future role for eE-
VAR in the treatment of RAAA but cannot be interpreted confi-
dently due to the nature of the studies.
6Endovascular treatment for ruptured abdominal aortic aneurysm (Review)
Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Implications for research
Further trials to evaluate the role of eEVAR in the treatment of
RAAA are required. These trials should be methodologically ade-
quate in terms of sample sizes, treatment standardization and du-
ration of follow up. Clinically-relevant outcomes such as rate of
major complications, open-conversion, aneurysm exclusion, en-
doleak, rupture, and mortality should be assessed. However, accu-
mulating evidence from non-randomised studies, which show sig-
nificant reductions in mortality in selected patients deemed suit-
able for endovascular repair, may raise ethical concerns in relation
to randomising these patients to open repair. Large prospective
studies are required to validate the acceptable anatomical criteria
for eEVAR in RAAA. Furthermore, longitudinal studies are re-
quired to assess the long-term durability of this form of treatment
in terms of re-intervention rate, open-conversion rate, and rup-
ture-free survival.
P O T E N T I A L C O N F L I C T O F
I N T E R E S T
None known.
A C K N O W L E D G E M E N T S
We would like to thank the external referee, Mr Paul Tisi for his
helpful comments and the Consumer Network for their contribu-
tion to the Plain Language Summary.
S O U R C E S O F S U P P O R T
External sources of support
• Chief Scientist Office, Health Department, The Scottish Exec-
utive UK
Internal sources of support
• Cochrane Fellowship, Research & Development Office, North-
ern Ireland UK
R E F E R E N C E S
References to studies excluded from this reviewAlsac 2005
Alsac JM, Desgranges P, Kobeiter H, Becquemin JP. Emergency en-
dovascular repair for ruptured abdominal aortic aneurysms: feasibil-
ity and comparison of early results with conventional open repair. Eu-
ropean Journal of Vascular & Endovascular Surgery 2005;30(6):632–9.
[MedLine: doi: 10.1016/j.ejvs.2005.06.010].
Brandt 2005
Brandt M, Walluscheck KP, Jahnke T, Graw K, Cremer J,
Muller-Hulsbeck S. Endovascular repair of ruptured aneurysm:
feasibility and impact on early outcome. Journal of Vascular
& Interventional Radiology 2005;16(10):1309–12. [MedLine: doi:
10.1097/01.RV1.0000175332.44635.49].
Castelli 2005
Castelli P, Caronno R, Piffaretti G, Tozzi M, Lagana D, Car-
rafiello G, et al. Ruptured abdominal aortic aneurysm: endovascular
treatment. Abdominal Imaging 2005;30(3):263–9. [MedLine: doi:
10.1007/s00261-004-0272-6].
Doss 2002
Doss M, Martens S, Hemmer W. Emergency endovascular inter-
ventions for ruptured thoracic and abdominal aortic aneurysms.
American Heart Journal 2002;144(3):544–8. [MedLine: doi:
10.1067/mhj.2002.123578].
Franks 2006
Franks S, Lloyd G, Fishwick G, Bown M, Sayers R. Endovascular
treatment of ruptured and symptomatic abdominal aortic aneurysms.
European Journal of Vascular & Endovascular Surgery 2006;31(4):
345–50. [MedLine: doi: 10.1016/j-ejvs.2005.08.037].
Gerassimidis 2005
Gerassimidis TS, Papazoglou KO, Kamparoudis AG, Konstantini-
dis K, Karkos CD, Karamanos D, et al. Endovascular management
of ruptured abdominal aortic aneurysms: 6-year experience from a
Greek center. Journal of Vascular Surgery 2005;42(4):615–23. [Med-
Line: doi: 10.1016/j.jvs.2005.05.061].
Greco 2006
Greco G, Egorova N, Anderson PL, Gelijns A, Moskowitz A,
Nowygrod R, et al. Outcomes of endovascular treatment of ruptured
abdominal aortic aneurysms. Journal of Vascular Surgery 2006;43(3):
453–9. [MedLine: doi: 10.1016/j.jvs.2005.11.024].
Greenberg 2000
Greenberg RK, Srivastava SD, Ouriel K, Waldman D, Ivancev K,
Illig KA, et al. An endoluminal method of haemorrhage control and
repair of ruptured abdominal aortic aneurysms. Journal of Endovas-
cular Therapy 2000;7(1):1–7.
Hechelhammer 2005
Hechelhammer L, Lachat ML, Wildermuth S, Bettex D, Mayer D,
Pfammatter T. Midterm outcome of endovascular repair of ruptured
abdominal aortic aneurysms. Journal of Vascular Surgery 2005;41(5):
752–7. [MedLine: doi: 10.1016/j.jvs2005.02.023].
Hinchliffe 2001
Hinchliffe RJ, Yusuf SW, Macierewicz JA, MacSweeney STR, Wen-
ham PW, Hopkinson BR. Endovascular repair of ruptured abdom-
inal aortic aneurysm - a challenge to open repair? Results of a
single centre experience in 20 patients. European Journal of Vas-
7Endovascular treatment for ruptured abdominal aortic aneurysm (Review)
Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
cular & Endovascular Surgery 2001;22(6):528–34. [MedLine: doi:
10.1053/ejvs.2001.1513].
Kapma 2005
Kapma MR, Verhoeven EL, Tielliu IF, Zeebregts CJ, Prins TR,
Van der Heij B, et al. Endovascular treatment of acute abdominal
aortic aneurysm with a bifurcated stentgraft. European Journal of
Vascular & Endovascular Surgery 2005;29(5):510–5. [MedLine: doi:
10.1016/j.ejvs.2005.01.007].
Lachat 2002
Lachat ML, Pfammatter T, Witzke HJ, Bettex D, Kunzli A, Wolfens-
berger U, Turina MI. Endovascular repair with bifurcated stent-grafts
under local anaesthesia to improve outcome of ruptured aortoil-
iac aneurysms. European Journal of Vascular & Endovascular Surgery
2002;23(6):528–36. [MedLine: doi: 10.1053/ejvs.2002.1622].
Lagana 2006
Lagana D, Carrafiello G, Mangini M, Fontana F, Caronno R, Castelli
P, et al. Emergency endovascular treatment of abdominal aortic
aneurysms: feasibility and results. Cardiovascular & Interventional Ra-
diology 2006;29(2):241–8.
Larzon 2005
Larzon T, Lindgren R, Norgren L. Endovascular treatment of rup-
tured abdominal aortic aneurysms: a shift of the paradigm?. Journal
of Endovascular Therapy 2005;12(5):548–55. [MedLine: doi:].
Larzon T, Lindgren R, Norgren L. Endovascular treatment possible
in ruptured abdominal aortic aneurysm [Endovaskular metod mojlig
vid rupturerade bukaortaaneurysm]. Lakartidningen 2005;102(17):
1320–5.
Lee 2004
Lee WA, Herniese CM, Tayyarah M, Huber TS, Seeger JM. Impact of
endovascular repair on early outcomes of ruptured abdominal aortic
aneurysms. Journal of Vascular Surgery 2004;40(2):211–5. [MedLine:
doi: 10.1016/j.jvs.2004.05.006].
Lombardi 2004
Lombardi JV, Fairman RM, Golden MA, Carpenter JP, Mitchell M,
Barker C, et al. The utility of commercially available endografts in
the treatment of contained ruptured abdominal aortic aneurysm with
haemodynamic stability. Journal of Vascular Surgery 2004;40(1):154–
60. [MedLine: doi: 10.1016/j.jvs.2004.02.042].
Mehta 2005
Mehta M, Darling RC 3rd, Roddy SP, Fecteau S, Ozsvath KJ, Kreien-
berg PB, et al. Factors associated with abdominal compartment
syndrome complicating endovascular repair of ruptured abdominal
aortic aneurysms. Journal of Vascular Surgery 2005;42(6):1047–51.
[MedLine: doi: 10.1016/j.jvs.2005.08.033].
Ohki 2000
Ohki T, Veith FJ. Endovascular grafts and other image-guided
catheter-based adjuncts to improve the treatment of ruptured aor-
toiliac aneurysms. Annals of Surgery 2000;232(4):466–79.
Okhi 1999
Okhi T, Veith FJ, Sanchez LA, Cynamon J, Lipsitz EC, Wain RA, et
al. Endovascular graft repair of ruptured aortoiliac aneurysms. Journal
of the American College of Surgeons 1999;189(1):102–12.
Orend 2002
Orend KH, Kotsis T, Scharrer-Pamler R, Kapfer X, Liewald F, Gorich
J, et al. Endovascular repair of aortic rupture due to trauma and
aneurysm. European Journal of Vascular & Endovascular Surgery 2002;
23(1):61–7. [MedLine: doi: 10.1053/ejvs.2001.1546].
Peppelenbosch 2003
Peppelenbosch N, Yilmaz N, van Marrewijk C, Buth J, Cuypers P,
Duijm L, et al. Emergency treatment of acute symptomatic or rup-
tured abdominal aortic aneurysm. Outcome of a prospective intent-
to-treat by EVAR protocol. European Journal of Vascular & Endovas-
cular Surgery 2003;26(3):303–10. [MedLine: doi: 10.1016/S1078-
5884(03)00244-2].
Peppelenbosch 2005
Peppelenbosch N, Cuypers PW, Vahl AC, Vermassen F, Buth
J. Emergency endovascular treatment for ruptured abdomi-
nal aortic aneurysm and the risk of spinal cord ischaemia.
Journal of Vascular Surgery 2005;42(4):608–14. [MedLine: doi:
10.1016/j.jvs.2005.06.023].
Reichart 2003
Reichart M, Geelkerken RH, Huisman AB, van Det RJ, de Smit P,
Volker EP. Ruptured abdominal aortic aneurysm: endovascular repair
is feasible in 40% of patients. European Journal of Vascular & Endovas-
cular Surgery 2003;26(5):479–86. [MedLine: doi: 10.1016/S1078-
5884(03)00346-0].
Resch 2003
Resch T, Malina M, Lindblad B, Dias NV, Sonesson B, Ivancev K.
Endovascular repair of ruptured abdominal aortic aneurysms: logis-
tics and short-term results. Journal of Endovascular Therapy 2003;10
(3):440–6. [MedLine: doi:].
Rubin 2004
Rubin BG, Sanchez LA, Choi ET, Sicard GA. Endoluminal repair of
ruptured abdominal aortic aneurysms under local anaesthesia: initial
experience. Vascular & Endovascular Surgery 2004;38(3):203–7.
Scharrer-Pamler 2003
Scharrer-Pamler R, Kotsis T, Kapfer X, Gorich J, Sunder-Plassmann
L. Endovascular stent-graft repair of ruptured aortic aneurysms. Jour-
nal of Endovascular Therapy 2003;10(3):447–52.
Vaddineni 2005
Vaddineni SK, Russo GC, Patterson MA, Taylor SM, Jordan WD Jr.
Ruptured abdominal aortic aneurysm: a retrospective assessment of
open versus endovascular repair. Annals of Vascular Surgery 2005;19
(6):782–6. [MedLine: doi: 10.1007/s10016-005-7975-1].
van Herzeele 2003
van Herzeele I, Vermassen F, Durieux C, Randon C, De Roose
J. Endovascular repair of aortic rupture. European Journal of Vas-
cular & Endovascular Surgery 2003;26(3):311–6. [MedLine: doi:
10.1016/S1078-5884(03)00297-1].
van Sambeek 2002
van Sambeek MR, van Dijk LC, Hendriks JM, van Grotel M, Kuiper
JW, Pattynama PM, et al. Endovascular versus conventional open
repair of acute abdominal aortic aneurysm: feasibility and preliminary
results. Journal of Endovascular Therapy 2002;9(4):443–8.
Verhoeven 2002
Verhoeven EL, Prins TR, van den Dungen JJ, Tielliu IF, Hulsebos
RG, van Schilfgaarde R. Endovascular repair of acute AAAs under
local anaesthesia with bifurcated endografts: a feasibility study. Jour-
nal of Endovascular Therapy 2002;9(6):729–35.
8Endovascular treatment for ruptured abdominal aortic aneurysm (Review)
Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Yilmaz 2002
Yilmaz N, Peppelenbosch N, Cuypers PW, Tielbeek AV, Duijm LE,
Buth J. Emergency treatment of symptomatic or ruptured abdominal
aortic aneurysms: the role of endovascular repair. Journal of Endovas-
cular Therapy 2002;9(4):449–57.
Additional references
Adam 1999
Adam DJ, Mohan IV, Stuart WP, Bain M, Bradbury AW. Commu-
nity and hospital outcome from ruptured abdominal aortic aneurysm
within the catchment area of a regional vascular surgical service. Jour-
nal of Vascular Surgery 1999;30(5):922–8.
Alsac 2005b
Alsac JM, Kobeiter H, Becquemin JP, Desgranges P. Endovascular
repair for ruptured AAA: a literature review. Acta Chirurgica Belgica
2005;105(2):134–9.
Ashton 2002
Ashton HA, Buxton MJ, Day NE, Kim LG, Marteau TM, Scott RA,
Thompson SG, Walker NM, Multicentre Aneurysm Screening Study
Group. The Multicentre Aneurysm Screening Study (MASS) into
the effect of abdominal aortic aneurysm screening on mortality in
men: a randomised controlled trial. Lancet 2002;360(9345):1531–9.
Bown 2003
Bown MJ, Nicholson ML, Bell PR, Sayers RD. The systemic inflam-
matory response syndrome, organ failure and mortality after abdom-
inal aortic aneurysm repair. Journal of Vascular Surgery 2003;37(3):
600–6.
Boyle 2005
Boyle JR, Gibbs PJ, Kruger A, Shearman CP, Raptis S, Phillips MJ.
Existing delays following the presentation of ruptured abdominal
aortic aneurysm allow sufficient time to assess patients for endovascu-
lar repair. European Journal of Vascular & Endovascular Surgery 2005;
29(5):505–9.
Corso 2005
Corso JE, Kasirajan K, Milner R. Endovascular Management of rup-
tured, mycotic abdominal aortic aneurysm. American Surgeon 2005;
71(6):515–7.
Cuypers 2001
Cuypers PWM, Gardien M, Buth J, Peels CH, Charbon JA, Hop
WC. Randomized study comparing cardiac response in endovascular
and open aortic aneurysm repair. British Journal of Surgery 2001;88
(8):1059–65.
EVAR 2004
Greenhalgh RM, Brown LC, Kwong GP, Powell JT, Thompson SG.
EVAR trial participants. Comparison of Endovascular aneurysm re-
pair with open repair in patients with abdominal aortic aneurysm
(EVAR trial 1), 30-day operative mortality results: randomised con-
trolled trial. Lancet 2004;364(9437):843–8.
EVAR 2005
EVAR trial participants. Endovascular aneurysm repair versus open
repair in patients with abdominal aortic aneurysm (EVAR trial 1):
randomised controlled trial. Lancet 2005;365(9478):2179–86.
EVAR2 2005
EVAR trial participants. Endovascular aneurysm repair and outcome
in patients unfit for open repair of abdominal aortic aneurysm (EVAR
trial 2): randomised controlled trial. Lancet 2005;365(9478):2187–
92.
Gorham 2004
Gorham TJ, Taylor J, Raptis S. Endovascular treatment of abdominal
aortic aneurysm. British Journal of Surgery 2004;91(7):815–27.
Greenhalgh 1998
Greenhalgh RM, Forbes JF, Fowkes FG, Powell JT, Ruckley CV,
Brady AR, et al. Early elective open surgical repair of small abdom-
inal aortic aneurysms is not recommended: results of the UK Small
Aneurysm Trial. Steering Committee. European Journal of Vascular
& Endovascular Surgery 1998;16(6):462–4.
Harris 1991
Harris LM, Faggioli GL, Fiedler R, Curl GR, Ricotta JJ. Ruptured
abdominal aortic aneurysms: factors affecting mortality rates. Journal
of Vascular Surgery 1991;14(6):812–8.
Harris 2005
Harris P, Buth J, Eurostar, Beard J, RETA. What is the future for reg-
istries on endovascular aneurysm repair and who should be respon-
sible?. European Journal of Vascular & Endovascular Surgery 2005;30
(4):343-5 2005;30(4):343–5.
Hinchcliffe 2002
Hinchliffe RJ, Yung M, Hopkinson BR. Endovascular exclusion of
a ruptured pseudoaneurysm of the infrarenal abdominal aorta sec-
ondary to pancreatitis. Journal of Endovascular Therapy 2002;9(5):
590–2.
Hinchliffe 2003
Hinchliffe RJ, Braithwaite BD, Hopkinson BR. The endovascu-
lar management of ruptured abdominal aortic aneurysms. European
Journal of Vascular & Endovascular Surgery 2003;25(3):191–201.
Hinterseher 2004
Hinterseher I, Saeger HD, Koch R, Bloomenthal A, Ockert D, Berg-
ert H. Quality of life and long-term results after ruptured abdominal
aortic aneurysm. European Journal Vascular & Endovascular Surgery
2004;28(3):262–9.
Huber 1995
Huber TS, Harward TR, Flynn TC, Albright JL, Seeger JM. Oper-
ative mortality rates after elective infrarenal aortic reconstructions.
Journal of Vascular Surgery 1995;22(3):287–93.
Korhonen 2004
Korhonen SJ, Ylonen K, Biancari F, Heikkinen M, Salenius J-P, Lep-
antalo M. Finnvasc Study Group. Glasgow Aneurysm Score as a pre-
dictor of immediate outcome after surgery for ruptured abdominal
aortic aneurysm. British Journal of Surgery 2004;91(11):1449–52.
Kumar 2002
Kumar V, Campbell JH, Andy OJ, Hatten LE. Emergent repair of
a ruptured abdominal aortic aneurysm using an AneuRx stent-graft.
Journal of Endovascular Therapy 2002;9(2):194–7.
Lederle 1997
Lederle FA, Johnson GR, Wilson SE, Chute EP, Littooy FN, Bandyk
D, et al. Prevalence and associations of abdominal aortic aneurysm
detected through screening. Aneurysm Detection and Management
(ADAM) Veterans Affairs Cooperative Study Group. Annals of Inter-
nal Medicine 1997;126(6):441–9.
9Endovascular treatment for ruptured abdominal aortic aneurysm (Review)
Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Lindsay 1999
Lindsay TF, Luo XP, Lehotay DC, Rubin BB, Anderson M, Walker
PM, et al. Ruptured abdominal aortic aneurysm, a “two-hit” is-
chaemia/reperfusion injury: evidence from an analysis of oxidative
products. Journal of Vascular Surgery 1999;30(2):219–28.
Lloyd 2004
Lloyd GM, Bown MJ, Norwood MG, Deb R, Fishwick G, Bell PR,
et al. Feasibilty of preoperative computer tomography in patients
with ruptured abdominal aortic aneurysms: a time-to-death study in
patients without operation. Journal of Vascular Surgery 2004 2004
2004;39(4):788–91.
Morales 2005
Morales JP, Irani FG, Jones KG, Taylor PR, Dourado R, Sabharwal T.
Endovascular repair of a ruptured abdominal aortic aneurysm under
local anaesthesia. British Journal of Radiology 2005;78(925):62–4.
Neary 2003
Neary WD, Crow P, Foy C, Prytherch D, Heather BP, Earnshaw JJ.
Comparison of POSSUM scoring and the Hardman Index in selec-
tion of patients for repair of ruptured abdominal aortic aneurysm.
British Journal of Surgery 2003;90(4):421–5.
Norman 2004
Norman PE, Jamrozik K, Lawrence-Brown MM, Le MT, Spencer
CA, Tuohy RJ, et al. Population based randomised controlled trial on
impact of screening on mortality from abdominal aortic aneurysm.
BMJ 2004;329(7477):1259.
Parodi 1991
Parodi JC, Palmaz JC, Barone HD. Transfemoral intraluminal graft
implantation for abdominal aortic aneurysms. Annals of Vascular
Surgery 1991;5(6):491–9.
Powell 2003
Powell JT. Familial clustering of abdominal aortic aneurysm-- smoke
signals, but no culprit genes. British Journal of Surgery 2003;90(10):
1173–4.
Prinssen 2004
Prinssen M, Verhoeven ELG, Buth J, Cuypers PW, van Sambeek MR,
Balm R, Buskens E, et al. A randomized controlled trial comparing
comparing conventional and endovascular repair of abdominal aortic
aneurysms. New England Journal of Medicine 2004;351(16):1607–
18.
Roumen 1993
Roumen RM, Hendriks T, van der Ven-Jongekrijg J, Nieuwenhuijzen
GA, Sauerwein RW, van der Meer JW, et al. Cytokine patterns in
patients after major vascular surgery, haemorrhagic shock and severe
blunt trauma. Relation with subsequent adult respiratory distress
syndrome and multiple organ failure. Annals of Surgery 1993;218(6):
769–76.
Scott 1991
Scott RA, Ashton, HA, Kay DN. Abdominal aortic aneurysm in
4237 screened patients: prevalence, development and management
over 6 years. British Journal of Surgery 1991;78(9):1122–5.
Scott 1995
Scott RA, Wilson NM, Ashton HA, Kay DN. Influence of screen-
ing on the incidence of ruptured abdominal aortic aneurysm: 5-year
results of a randomized controlled study. British Journal of Surgery
1995;82(8):1066–70.
Seelig 2000
Seelig MH, Berchtold C, Jakob P, Schonleben K. Contained rupture
of an infrarenal abdominal aortic aneurysm treated by endoluminal
repair. European Journal of Vascular & Endovascular Surgery 2000;19
(2):202–4.
Tambyraja 2004
Tambyraja AL, Fraser SC, Murie JA, Chalmers RT. Quality of life
after repair of ruptured abdominal aortic aneurysm. European Journal
of Vascular & Endovascular Surgery 2004;28(3):229–33.
Thomas 2005
Thomas SM, Beard JD, Ireland M, Ayers S. Vascular Society of Great
Britain and Ireland, British Society of Interventional Radiology. Re-
sults from the propsective registry of endovascular treatment of ab-
dominal aortic aneuryms (RETA): mid-term results to five years. Eu-
ropean Journal of Vascular & Endovascular Surgery 2005;29(6):563–
70.
van Vlijmen 2002
van-Vlijmen-van Keulen CJ, Pals G, Rauwerda JA. Familial abdomi-
nal aortic aneurysm: a systematic review of a genetic background. Eu-
ropean Journal of Vascular & Endovascular Surgery 2002;24(2):105–
16.
Veith 2003
Veith FJ, Ohki T, Lipsitz EC, Suggs WD, Cynamon J. Treatment of
ruptured abdominal aortic aneurysms with stent grafts: a new gold
standard?. Seminars in Vascular Surgery 2003;16(2):171–5.
Verhagen 2003
Verhagen HJ, Prinssen M, Milner R, Blankensteijn JD. Endoleak
after endovascular repair of ruptured abdominal aortic aneurysm: is
it a problem?. Journal of Endovascular Therapy 2003;10(4):766–71.
Wilmink 1999
Wilmink TB, Quick CR, Day NE. The association between cigarette
smoking and abdominal aortic aneurysms. Journal of Vascular Surgery
1999;30(6):1099–105.
Wilson 2004
Wilson WR, Fishwick G, Bell SP, Thompson MM. Suitability of
ruptured AAA for endovascular repair. Journal of Endovascular Ther-
apy 2004;11(6):635–40.
Yusuf 1994
Yusuf SW, Whitaker SC, Chuter TA, Wenham PW, Hopkinson BR.
Emergency endovascular repair of leaking aortic aneurysm (letter).
Lancet 1994; Vol. 344, issue 8937:1645.
10Endovascular treatment for ruptured abdominal aortic aneurysm (Review)
Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
T A B L E S
Characteristics of excluded studies
Study Reason for exclusion
Alsac 2005 Case series of consecutive patients with RAAA 2001-2004.
17/34 eEVAR compared to 20/34 OPEN.
Brandt 2005 Retrospective review of consecutive patients with RAAA 2001-2004. Patients 01/02 group (OPEN only) were
used as historical controls compared to 03/04 group (OPEN and eEVAR).
Castelli 2005 Retrospective review of patients treated with eEVAR for RAAA 2001-2004. 46 eEVAR.
Doss 2002 Retrospective review of endovascular stenting of ruptured thoracic or abdominal aortic aneurysms 1996-1998.
6/9 abdominal eEVAR.
Franks 2006 Retrospective study of eEVAR compared to historical OPEN repair controls in symptomatic and ruptured
AAA. 21 eEVAR, 23 OPEN.
Gerassimidis 2005 Retrospective review of 40 consecutive patients with RAAA 1998-2004. 23/40 underwent eEVAR.
Greco 2006 Retrospective data collection from discharge summaries in 4 USA states comparing outcomes between eEVAR
and OPEN repair of RAAA.
Greenberg 2000 Case reports of 3 patients treated with eEVAR for RAAA
Hechelhammer 2005 Retrospective Review of 37 patients with RAAA treated with eEVAR
Hinchliffe 2001 Prospective study of RAAA patients 1994-2000. 20 patients underwent eEVAR. No controls.
Kapma 2005 Retrospective review of 262 patients with RAAA 1998- 2004. 40 underwent eEVAR. Subgroup analysis of
2003-2004 cohort to evaluate applicability and suitability.
Lachat 2002 Prospective study of 21 consecutive patients who underwent eEVAR for ruptured aorto-iliac aneurysms. No
controls.
Lagana 2006 Retrospective review of 30 patients who underwent eEVAR 01-04. No controls.
Larzon 2005 Retrospective review of 50 consecutive patients with RAAA 2001-2004. 15/50 eEVAR, 26/50 OPEN , 9/50
Not operated on.
Lee 2004 Retrospective review of records of 36 consecutive patients with RAAA 1997-2004. 19/36 OPEN treated 1997-
2001 compared to 4/36 OPEN and 13/36 eEVAR treated 2001-2004
Lombardi 2004 Case Series of 5 patients with RAAA treated with eEVAR who were deemed unfit for conventional open surgical
repair.
Mehta 2005 Retrospective Review of 30 eEVAR patients 2002-2004 to evaluate risk factors for Abdominal Compartment
Syndrome
Ohki 2000 Retrospective Review of RAAA 25 patients 1994-2000. 20 underwent eEVAR.
Okhi 1999 Case Series of 12 consecutive patients with ruptured aortoiliac aneurysms treated with customized stent grafts
Orend 2002 Retrospective review of endovascular treatment of thoracic and abdominal aortic rupture due to aneurysm and
trauma
Peppelenbosch 2003 Prospective study of 40 consecutive patients with symptomatic or RAAA in whom eEVAR was the preferential
management compared with 28 historical controls who underwent OPEN repair for symptomatic or RAAA.
Peppelenbosch 2005 Retrospective multicentre study of 35 patients treated with eEVAR for RAAA 2001-2004 to evaluate the risk
of spinal cord ischaemia.
Reichart 2003 Prospective study of consecutive patients with symptomatic of ruptured AAA. 6/26 underwent eEVAR
11Endovascular treatment for ruptured abdominal aortic aneurysm (Review)
Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Resch 2003 Prospective study of 21 patients with RAAA undergoing eEVAR (1997-2002). Retrospective analysis to evaluate
why 23 patients underwent OPEN repair compared to 14 contemparaneous patients who underwent eEVAR
for RAA (2001-2002).
Rubin 2004 Case Review of 5 patients undergoing eEVAR
Scharrer-Pamler 2003 Prospective study of eEVAR in 24 patients with RAAA.
Vaddineni 2005 Retrospective review of 24 consecutive patients with RAAA 1999-2004. 9/24 eEVAR compared to 15/24
OPEN
Verhoeven 2002 Prospective Study of 47 patients with acute AAA (RAAA and Symptomatic). 16 underwent eEVAR compared
to OPEN surgical cohort.
Yilmaz 2002 Retrospective review of 24 patients with ruptured or symptomatic AAA treated with eEVAR 1999-2001. No
controls.
van Herzeele 2003 Retrospective non randomised study evaluating use of eEVAR in thoracic and abdominal aortic rupture. 9
RAAA included. No controls
van Sambeek 2002 Retropsective review of eEVAR compared to OPEN repair of RAAA in 22 consecutive patients with RAAA
(January - July 2001). 6/22 eEVAR
A D D I T I O N A L T A B L E S
Table 01. Search strategy used to search CENTRAL
Search terms
#1 MeSH descriptor Aortic Aneurysm, Abdominal explode all trees
#2 abdominal next aortic next aneurysm* in All Text
#3 aortic next aneurysm* in All Text
#4 (abdominal in All Text near/6 aortic in All Text near/6 aneurysm* in All Text)
#5 (abdominal in All Text near/6 aneurysm* in All Text)
#6 MeSH descriptor AORTIC ANEURYSM explode trees 1 and 2
#7 MeSH descriptor AORTIC RUPTURE explode trees 1, 2, 3 and 4
#8 (aortic next aneurysm in All Text near/6 rupture* in All Text)
#9 traumatic next aortic next rupture* in All Text
#10 (#1 or #2 or #3 or #4 or #5 or #6 or #7 or #8 or #9)
#11 endovascular next repair in All Text
#12 endovascular next aneurysm next repair in All Text
#13endovascular next aneurysm next treatment in All Text
#14endovascular next treatment in All Text
#15(#11 or #12 or #13 or #14)
#16(#10 and #15)
Table 02. Mortality
Study EVRAR group OPEN group p value (if quoted)
Alsac 2005 4/17 (23.5%) 10/20 (50%) 0.09
Brandt 2005 0/11 (0%) 2/13 (15%) NS
Franks 2006 11% 54% 0.02
Greco 2005 114/290 (39.3%) 2627/5508 (47.7%) 0.05
12Endovascular treatment for ruptured abdominal aortic aneurysm (Review)
Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Table 02. Mortality (Continued )
Study EVRAR group OPEN group p value (if quoted)
Kapma 2005 5/40 (13%) 64/213 (30%) 0.02
Larzon 2005 2/5 (13%) 12/26 (46%) >0.05
Ohki 2000 2/20 (10%) 0/5 (0%)
Peppelenbosch 2003 4/26 (15%) 4/14 (28%)
Peppelenbosch 2005 8/35 (23%) 19/66 (29%)
Reichart 2003 1/6 (16.6%) 4/13 (30%)
Resch 2003 4/14 (29%) 8/23 (35%)
Vaddenini 2005 2/9 (22%) 4/15 (26%)
Verhoeven 2002 1/16 (6%) 7/31 (23%)
Yilmaz 2002 4/24 (17%) 13/40 (32%)
Table 03. Length of ICU stay
Study EVRAR group OPEN group p value (if quoted)
Alsac 2005 3 13 <0.01
Brandt 2005 4.8 8.5 NS
Franks 2006 1.3 6.1 0.01
Kapma 2005 median 0 hours 48 hours <0.001
Peppelenbosch 2003 median 46 hours 154 hours
Reichart 2003 2.25 days 13 days
Resch 2003 median 1 day 3 days 0.02
Vaddenini 2005 median 5 days 20 days
van Sambeek 2002 median 8 hours 62 hours 0.004
Yilmaz 2002 mean 2.2 days 5.2 days <0.05
Table 04. Length of Procedure
Study EVRAR group OPEN group p value (if quoted)
Alsac 2005 156 min 2222 min <0.1
Brandt 2005 178 min 207 min NS
Franks 2006 156 min 186 min 0.04
Kapma 2005 median 110 min 180 min <0.001
Ohki 2000 median 336 min 492 min
13Endovascular treatment for ruptured abdominal aortic aneurysm (Review)
Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Table 04. Length of Procedure (Continued )
Study EVRAR group OPEN group p value (if quoted)
Peppelenbosch 2003 mean 154 min 155 min
Vaddenini 2005 mean 143 min 181 min
Verhoeven 2002 mean 110 min 122.5 min
van Sambeek 2002 mean 193 min mean 203 min NS
Yilmaz 2002 mean 173 min 273 min p<0.05
Table 05. Blood loss
Study EVRAR group OPEN group p value (if quoted)
Kapma 2005 median 200ml 3500ml <0.001
Ohki 2000 median 400ml 2000 ml
Peppelenbosch 2003 1100ml 2600ml
Reichart 2003 mean 300ml 4500ml
Resch 2003 800ml 4000ml 0.0001
Vaddenini 2005 475ml 2880ml 0.0001
van Sambeek 2002 median 125ml 3400ml 0.01
Yilmaz 2002 660ml 3550ml <0.05
Table 06. Transfusion requirements
Study EVRAR group OPEN group p value ( if quoted)
Alsac 2005 1520ml 3075ml <0.1
Brandt 2005 964ml 1986ml 0.02
Franks 2006 0.86units 10.7units <0.01
Kapma 2005 median 0 units 6 units <0.001
Ohki 2000 median 3 units 6 units
Reichart 2003 0 1600ml
Resch 2003 2 units 9 units 0.02
Vaddenini 2005 3.78 units 6.93 units 0.014
G R A P H S A N D O T H E R T A B L E S
This review has no analyses.
C O V E R S H E E T
Title Endovascular treatment for ruptured abdominal aortic aneurysm
14Endovascular treatment for ruptured abdominal aortic aneurysm (Review)
Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Authors Dillon M, Cardwell C, Blair PH, Ellis P, Kee F, Harkin DW
Contribution of author(s) Marianne Dillon and Denis W Harkin performed the literature searches, identified all
possible trials, considered them for inclusion and assessed trial quality.
Paul Blair, Peter Ellis, Chris Cardwell and Frank Kee acted as arbitrators where disagreements
over inclusion and quality of studies occurred during the review process.
Issue protocol first published 2005/2
Review first published 2007/1
Date of most recent amendment 14 November 2006
Date of most recent
SUBSTANTIVE amendment
01 November 2006
What’s New Information not supplied by author
Date new studies sought but
none found
30 October 2006
Date new studies found but not
yet included/excluded
Information not supplied by author
Date new studies found and
included/excluded
11 November 2005
Date authors’ conclusions
section amended
Information not supplied by author
Contact address Dr Marianne Dillon
Vascular Surgery Unit
Royal Victoria Hospital
Grosvenor Road
Belfast
Northern Ireland
UK
E-mail: mariannedillon@doctors.org
Tel: +44 028 90240503
DOI 10.1002/14651858.CD005261.pub2
Cochrane Library number CD005261
Editorial group Cochrane Peripheral Vascular Diseases Group
Editorial group code HM-PVD
15Endovascular treatment for ruptured abdominal aortic aneurysm (Review)
Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd