J Korean Med Sci.  2023 Oct;38(39):e321. 10.3346/jkms.2023.38.e321.

Treatment Outcomes of Patients With Ruptured Abdominal Aortic Aneurysms

• Kim H
• Kwon TW
• Cho YP
• Gwon JG
• Han Y
• Lee SA
• Kim YJ
• Kim S

• KMID: 2546923
• DOI: http://doi.org/10.3346/jkms.2023.38.e321

Abstract

Background
Ruptured abdominal aortic aneurysm (rAAA) is a serious complication of abdominal aortic aneurysm associated with high operative mortality and morbidity rates. The present study evaluated the perioperative and long-term outcomes of Korean patients with rAAA based on national health insurance claims data.
Methods
The National Health Insurance Service (NHIS) database was searched retrospectively to identify patients with rAAA who underwent endovascular aneurysm repair (EVAR) and open surgical repair (OSR) from 2009 to 2018. Perioperative (≤ 30 days), early postoperative (≤ 3 month), and long-term (> 3 month) survival, reinterventions, and complications were assessed.
Results
The search identified 1,034 patients with rAAA, including 594 who underwent EVAR and 440 who underwent OSR. When the study period was divided into two, the total numbers of patients with rAAA, patients who underwent EVAR, and octogenarians were higher during the second half. The perioperative mortality rate was 29.8% in the EVAR and 35.0% in the OSR group (P = 0.028). Hartmann’s procedure for bowel infarction was performed more frequently in the OSR than in the EVAR group (adjusted odds ratio, 6.28; 95% confidence interval [CI], 2.33–21.84; P = 0.001), but other complication rates did not differ significantly. All-cause mortality during the entire observation period did not differ significantly in the EVAR and OSR groups (adjusted hazard ratio, 1.17; 95% CI, 0.98–1.41; P = 0.087). Abdominal aortic aneurysm-related reintervention rate was significantly lower in the OSR group (adjusted hazard ratio, 0.31; 95% CI, 0.14–0.70; P = 0.005).
Conclusion
Although EVAR showed somewhat superior perioperative outcomes for rAAA, the long-term outcomes of EVAR after excluding initial 3 months were significantly worse than OSR. When anatomically feasible for both treatments, the perioperative mortality risk and reasonable prospects of long-term survival should be considered in rAAA.

Keyword

Aortic Aneurysm; Abdominal; Aneurysm; Ruptured; Mortality; Complication; Peroperative; Endovascular Abdominal Aortic Repair; Open Abdomen Techniques

Figure

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  Fig. 1 Flow diagram.NHIS = National Health Insurance Service, ICD-10 = International Classification of Diseases-Tenth Revision, AAA = abdominal aortic aneurysm, OSR = open surgical repair, EVAR = endovascular aneurysm repair.

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  Fig. 2 Annual standardised incidence rates of patients treated for ruptured abdominal aortic aneurysm per 100,000 population from 2009 to 2018 (A) and number of patients with ruptured abdominal aortic aneurysm by age group (B). Groups were standardised relative to the numbers of persons aged ≥ 50 years in Korea in 2005 (11,302,213 persons).

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  Fig. 3 Forest plot comparing perioperative outcomes, including perioperative complications and mortality, in patients who underwent EVAR or OSR for ruptured abdominal aortic aneurysms. The OR was calculated with EVAR as the reference. The adjusted OR was calculated by adjusting for age and sex.EVAR = endovascular aneurysm repair, OSR = open surgical repair, OR = odds ratio, CI = confidence interval.

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  Fig. 4 Mortality rates of patients who underwent EVAR and OSR for ruptured abdominal aortic aneurysms over time (A) and cumulative incidence of reintervention, with death considered a competing risk (B).EVAR = endovascular aneurysm repair, OSR= open surgical repair.

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  Fig. 5 Forest plot comparing all-cause mortality, mortality at ≤ 3 months, mortality at > 3 months, and reintervention in patients who underwent EVAR or OSR for ruptured abdominal aortic aneurysms. The HR was calculated with EVAR as the reference. The adjusted HR was calculated by adjusting for age and sex.EVAR = endovascular aneurysm repair, OSR = open surgical repair, HR = hazard ratio, CI = confidence interval.aLong-term mortality was calculated after excluding initial 3 months’ outcome.bThe reintervention rate considered death as a competing risk.

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