Endovascular repair of ruptured abdominal aortic aneurysm: A strategy in need of definitive evidence

IntroductionEndovascular strategies have been increasingly used to manage patients with ruptured abdominal aortic aneurysm (AAA) in an attempt to improve patient survival. We analyzed the evidence to support such an approach.MethodsWe performed a systematic literature review of endovascular aneurysm repair (EVAR) of ruptured AAA from 1994 to 2009. The literature analyzed included systematic reviews and population-based studies of ruptured AAA.ResultsSeven systematic reviews were identified, all demonstrating from published data that patients with EVAR of ruptured AAA had significantly reduced mortality compared with controls. Six recently published population-based studies from the United States demonstrated low mortality rates associated with EVAR; however, only a small proportion of ruptured AAAs were treated by EVAR. Systematic reviews and population-based studies both raised concerns about patient selection and publication bias. Two randomized trials are in progress, and one is due to commence 2009.ConclusionsThe outcome of EVAR in a nonselected patient population remains unknown. One or more definitive randomized trials could provide the level I evidence to resolve these issues

Comprehensive geriatric assessment in perioperative care: a protocol for a systematic review and qualitative synthesis

INTRODUCTION: Comprehensive geriatric assessment (CGA) is an intervention that has been deployed in the perioperative setting with the aim to improve outcomes for older patients admitted to hospital. Older patients undergoing surgery are more likely to have postoperative complications, a longer hospital stay and be discharged to a care facility. Despite the increasing application of this intervention within surgical services, the evidence for CGA remains limited in this group. The aim of this systematic review is to describe CGA as in intervention applied to surgical populations in randomised controlled trials (RCTs) as well as the outcomes assessed. METHODS AND ANALYSIS: A systematic search of RCTs of CGA in surgery will be run in Embase, Medline, CINAHL (Cumulative Index to Nursing and Allied Health Literature) and Cochrane library. Further articles will be identified from reference lists in relevant studies found in the search. A narrative synthesis will be undertaken outlining specialties included, detailed descriptions of the intervention and outcomes. ETHICS AND DISSEMINATION: No ethical approval is required. The results of this review will be published and used as the basis of work to optimise this intervention for future trials in surgical populations. PROSPERO REGISTRATION NUMBER: This review is registered with PROSPERO CRD42020221797

Editor's Choice - Re-interventions After Repair of Ruptured Abdominal Aortic Aneurysm: A Report From the IMPROVE Randomised Trial.

OBJECTIVE/BACKGROUND: The aim was to describe the re-interventions after endovascular and open repair of rupture, and investigate whether these were associated with aortic morphology. METHODS: In total, 502 patients from the IMPROVE randomised trial (ISRCTN48334791) with repair of rupture were followed-up for re-interventions for at least 3 years. Pre-operative aortic morphology was assessed in a core laboratory. Re-interventions were described by time (0-90 days, 3 months-3 years) as arterial or laparotomy related, respectively, and ranked for severity by surgeons and patients separately. Rare re-interventions to 1 year, were summarised across three ruptured abdominal aortic aneurysm trials (IMPROVE, AJAX, and ECAR) and odds ratios (OR) describing differences were pooled via meta-analysis. RESULTS: Re-interventions were most common in the first 90 days. Overall rates were 186 and 226 per 100 person years for the endovascular strategy and open repair groups, respectively (p = .20) but between 3 months and 3 years (mid-term) the rates had slowed to 9.5 and 6.0 re-interventions per 100 person years, respectively (p = .090) and about one third of these were for a life threatening condition. In this latter, mid-term period, 42 of 313 remaining patients (13%) required at least one re-intervention, most commonly for endoleak or other endograft complication after treatment by endovascular aneurysm repair (EVAR) (21 of 38 re-interventions), whereas distal aneurysms were the commonest reason (four of 23) for re-interventions after treatment by open repair. Arterial re-interventions within 3 years were associated with increasing common iliac artery diameter (OR 1.48, 95% confidence interval [CI] 0.13-0.93; p = .004). Amputation, rare but ranked as the worst re-intervention by patients, was less common in the first year after treatment with EVAR (OR 0.2, 95% CI 0.05-0.88) from meta-analysis of three trials. CONCLUSION: The rate of mid-term re-interventions after rupture is high, more than double that after elective EVAR and open repair, suggesting the need for bespoke surveillance protocols. Amputations are much less common in patients treated by EVAR than in those treated by open repair