Georgios Koudounas, Vangelis Bontinis, Stefanos Giannopoulos, Alkis Bontinis, Apostolos Tassiopoulos, Christos D Karkos
OBJECTIVE: To document the clinical presentation, management, and outcome of patients presenting with late rupture of abdominal aortic aneurysm (AAA) after previous endovascular repair (EVAR) and to investigate which factors may influence the perioperative mortality.
METHODS: A systematic review and meta-analysis of relevant studies was undertaken to February 2024 in conformity with the PRISMA guidelines. We included studies reporting on either endovascular or open surgical repair (OSR) of late rupture (>30 days) after previous EVAR. The primary endpoint was perioperative (in-hospital or 30-day) mortality. A random effects meta-analysis was conducted and a meta-regression was subsequently performed to examine the impact of several variables on perioperative mortality.
RESULTS: Thirty studies (743 patients, 746 ruptures) were included. The cumulative incidence of rupture-post-EVAR during a mean 5-year follow-up was 1.5%. Mean time from the index EVAR to rupture was 48 (range 16-81) months. The mean compliance to follow-up was 68% (95% confidence interval [CI] 58-77) and 32% (95% CI 24-40) of the cases had at least one previous aneurysm-related reintervention. Type I and III endoleaks were the predominant causes of rupture (88%). About a third of the patients (37%; 95% CI 28-47) were hemodynamically unstable. Of those undergoing an operation, 247 (38%) patients were managed endovascularly and 409 (62%) by OSR. The pooled perioperative mortality was 29.5% (30 studies; 95% CI 23.8-35.8) and was significantly lower in the endovascular subgroup (20 studies; risk ratio [RR] 0.62; 95% CI 0.44-0.86). Meta-regression demonstrated that perioperative mortality appears to fall in recent years (-0.0545; p=0.04), to decrease in larger series in the endovascular subgroup (-0.0375; p=0.01), and to be significantly higher when total endograft explantation is required in the OSR subgroup (0.0121, p=0.03).
CONCLUSIONS: Late rupture after previous EVAR is a devastating event with a considerable risk for death. An endovascular approach is associated with a significantly lower perioperative mortality and should be preferred whenever feasible. When open surgery is required, total endograft explantation carries a higher mortality and, therefore, preserving functional parts of the endograft should be encouraged.
