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• W2093008737 abstract "Mortality rates following repair of ruptured abdominal aortic aneurysms have remained depressingly high over the last number of decades despite advances in anesthesia and perioperative care. Prior to the introduction of endovascular repair, refinements in surgical technique had been few and far between. It was not until fairly recently that we finally observed a reduction in mortality coinciding with the wider adoption of endovascular repair. So, the case is closed, right? Endovascular repair should be widely adopted in all suitable patients? Well, not exactly. The following debate centers around what level of evidence is required to answer this question.Frank Veith argues that we're already there. He was an early adopter and innovator of endovascular techniques and feels that we have enough information to widely adopt endovascular repair of ruptured aneurysms. Janet Powell and Robert Hinchliffe, innovators in their own right, feel that the generalizability and applicability of endovascular repair require further evaluation with a randomized trial. Both offer clear and reasoned arguments. Mortality rates following repair of ruptured abdominal aortic aneurysms have remained depressingly high over the last number of decades despite advances in anesthesia and perioperative care. Prior to the introduction of endovascular repair, refinements in surgical technique had been few and far between. It was not until fairly recently that we finally observed a reduction in mortality coinciding with the wider adoption of endovascular repair. So, the case is closed, right? Endovascular repair should be widely adopted in all suitable patients? Well, not exactly. The following debate centers around what level of evidence is required to answer this question. Frank Veith argues that we're already there. He was an early adopter and innovator of endovascular techniques and feels that we have enough information to widely adopt endovascular repair of ruptured aneurysms. Janet Powell and Robert Hinchliffe, innovators in their own right, feel that the generalizability and applicability of endovascular repair require further evaluation with a randomized trial. Both offer clear and reasoned arguments. —Frank J. Veith, MD, New York, NY, and Cleveland, Ohio This article addresses the question whether or not a randomized controlled trial (RCT) comparing endovascular repair (EVAR) with open repair for ruptured abdominal aortic aneurysms (RAAAs) is needed. Many single-center reports, meta-analyses, and population-based studies have shown a substantially lower 30-day mortality for EVAR than open repair in the RAAA setting. However, it is possible that this difference is due to patient selection, with open repair being sometimes used in higher-risk patients than EVAR. In addition, some comparative trials have failed to find better mortality outcomes after EVAR than after open repair. For this reason, RCTs have been proposed. A recently completed review of the collected world experience with EVAR for RAAAs included data from 13 centers in which EVAR was used to treat almost all RAAAs in patients with suitable anatomy irrespective of hemodynamic status or risk status. In these centers, the 30-day mortality for EVAR treatment was 19.7%, whereas 30-day mortality for open repair was 36.3% (P < .0001). Several treatment strategies, adjuncts, and technical factors were felt to be important in achieving this lower mortality for EVAR. These included use of a standardized RAAA protocol and adequate EVAR experience, fluid restriction and hypotensive hemostasis, appropriate techniques for achieving supraceliac aortic balloon control and use of such control only when necessary, early detection and appropriate treatment of abdominal compartment syndrome, and use of EVAR in the treatment of the worst-risk patients. Because of these results in the 13 centers, none of which would participate in a RCT of EVAR vs open repair for RAAAs and because of logistical and ethical considerations, it is concluded that a RCT is not needed to validate the preferential use of EVAR to treat RAAAs in patients with suitable anatomy for the procedure. Endovascular repair of a ruptured abdominal aortic aneurysm (RAAA) was first performed successfully by Marin et al on April 21, 1994.1Marin M.L. Veith F.J. Cynamon J. Sanchez L.A. Lyon R.T. Levine B.A. et al.Initial experience with transluminally placed endovascular grafts for the treatment of complex vascular lesions.Ann Surg. 1995; 222: 449-465Crossref PubMed Scopus (281) Google Scholar Another case was first reported by Yusuf et al in 1994.2Yusuf S.W. Whitaker S.C. Chuter T.A. Wenham P.W. Hopkinson B.R. Emergency endovascular repair of leaking aortic aneurysms.Lancet. 1994; 344: 1645Abstract PubMed Google Scholar Since then, many centers have used endovascular aneurysm repair (EVAR) to treat RAAAs, with varying results.3Lachat M.L. Pfammatter T. Witzke H.J. Bettex D. Dunzli A. Wolfensberger U. et al.Endovascular repair with bifurcated stent-grafts under local anaesthesia to improve outcome of ruptured aortoiliac aneurysms.Eur J Vasc Endovasc Surg. 2002; 23: 528-536Abstract Full Text PDF PubMed Scopus (160) Google Scholar, 4Veith F.J. Ohki T. Endovascular approaches to ruptured infrarenal aorto-iliac aneurysms.J Cardiovasc Surg. 2002; 3: 369-378Google Scholar, 5Veith F.J. Lachat M. Mayer D. Malina M. Holst J. Mehta M. et al.Collected world and single center experience with endovascular treatment of ruptured abdominal aortic aneurysms.Ann Surg. 2009; 250: 818-824Crossref PubMed Scopus (128) Google Scholar, 6Hechelhammer L. Lachat M.L. Wildermuth S. Bettex D. Mayer D. Pfammatter T. Midterm outcome of endovascular repair of ruptured abdominal aortic aneurysms.J Vasc Surg. 2005; 41: 752-757Abstract Full Text Full Text PDF PubMed Scopus (125) Google Scholar, 7Mehta M. Darling III, R.C. Roddy S.P. Fecteau S. Ozsvath K.J. Kreienberg P.B. et al.Factors associated with abdominal compartment syndrome complicating endovascular repair of ruptured abdominal aortic aneurysms.J Vasc Surg. 2005; 42: 1047-1051Abstract Full Text Full Text PDF PubMed Scopus (113) Google Scholar, 8Coppi G. Silingardi R. Gennai S. Saitta G. Ciardullo A.V. A single centre experience in open and endovascular treatment of hemodynamically unstable and stable patients with ruptured abdominal aortic aneurysms.J Vasc Surg. 2006; 44: 1140-1147Abstract Full Text Full Text PDF PubMed Scopus (99) Google Scholar, 9Moore R. Nutley M. Cina C.S. Motamedi M. Faris P. Abuznadah W. Improved survival after introduction of an emergency endovascular therapy protocol for ruptured abdominal aortic aneurysms.J Vasc Surg. 2007; 45: 443-450Abstract Full Text Full Text PDF PubMed Scopus (150) Google Scholar, 10Mayer D. Pfammatter T. Rancic Z. Hechelhammer L. Wilhelm M. Veith F.J. et al.10 years of emergency endovascular aneurysm repair for ruptured abdominal aortoiliac aneurysms—lessons learned.Ann Surg. 2009; 249: 510-515Crossref PubMed Scopus (46) Google Scholar, 11Peppelenbosch N. Yilmaz N. van Marrewijk C. Buth J. Cuypers P. Duijm L. et al.Emergency treatment of acute symptomatic or ruptured abdominal aortic aneurysm Outcome of a prospective intent-to-treat by EVAR protocol.Eur J Vasc Endovasc Surg. 2003; 26: 303-310Abstract Full Text Full Text PDF PubMed Scopus (107) Google Scholar, 12Hinchliffe R.J. Bruijstens L. MacSweeney S.T. Braithwaite B.D. A randomized trial of endovascular and open surgery for ruptured abdominal aortic aneurysm—results of a pilot study and lessons learned for future studies.Eur J Vasc Endovasc Surg. 2006; 32: 506-515Abstract Full Text Full Text PDF PubMed Scopus (124) Google Scholar, 13Peppelenbosch N. Geelkerken R.H. Soong C. Cao P. Steinmetz O.K. Teijink J.A. et al.Endograft treatment of ruptured abdominal aortic aneurysms using the Talent aortouniiliac system: an international multicenter study.J Vasc Surg. 2006; 43: 1111-1123Abstract Full Text Full Text PDF PubMed Scopus (132) Google Scholar Several groups have developed standardized systems of management in the RAAA setting, have used EVAR whenever possible, and have achieved good results with EVAR.3Lachat M.L. Pfammatter T. Witzke H.J. Bettex D. Dunzli A. Wolfensberger U. et al.Endovascular repair with bifurcated stent-grafts under local anaesthesia to improve outcome of ruptured aortoiliac aneurysms.Eur J Vasc Endovasc Surg. 2002; 23: 528-536Abstract Full Text PDF PubMed Scopus (160) Google Scholar, 4Veith F.J. Ohki T. Endovascular approaches to ruptured infrarenal aorto-iliac aneurysms.J Cardiovasc Surg. 2002; 3: 369-378Google Scholar, 5Veith F.J. Lachat M. Mayer D. Malina M. Holst J. Mehta M. et al.Collected world and single center experience with endovascular treatment of ruptured abdominal aortic aneurysms.Ann Surg. 2009; 250: 818-824Crossref PubMed Scopus (128) Google Scholar, 6Hechelhammer L. Lachat M.L. Wildermuth S. Bettex D. Mayer D. Pfammatter T. Midterm outcome of endovascular repair of ruptured abdominal aortic aneurysms.J Vasc Surg. 2005; 41: 752-757Abstract Full Text Full Text PDF PubMed Scopus (125) Google Scholar, 7Mehta M. Darling III, R.C. Roddy S.P. Fecteau S. Ozsvath K.J. Kreienberg P.B. et al.Factors associated with abdominal compartment syndrome complicating endovascular repair of ruptured abdominal aortic aneurysms.J Vasc Surg. 2005; 42: 1047-1051Abstract Full Text Full Text PDF PubMed Scopus (113) Google Scholar, 8Coppi G. Silingardi R. Gennai S. Saitta G. Ciardullo A.V. A single centre experience in open and endovascular treatment of hemodynamically unstable and stable patients with ruptured abdominal aortic aneurysms.J Vasc Surg. 2006; 44: 1140-1147Abstract Full Text Full Text PDF PubMed Scopus (99) Google Scholar, 9Moore R. Nutley M. Cina C.S. Motamedi M. Faris P. Abuznadah W. Improved survival after introduction of an emergency endovascular therapy protocol for ruptured abdominal aortic aneurysms.J Vasc Surg. 2007; 45: 443-450Abstract Full Text Full Text PDF PubMed Scopus (150) Google Scholar, 10Mayer D. Pfammatter T. Rancic Z. Hechelhammer L. Wilhelm M. Veith F.J. et al.10 years of emergency endovascular aneurysm repair for ruptured abdominal aortoiliac aneurysms—lessons learned.Ann Surg. 2009; 249: 510-515Crossref PubMed Scopus (46) Google Scholar In contrast, other authors have used EVAR for RAAAs more selectively and have reported no better results with EVAR than with traditional open repair.11Peppelenbosch N. Yilmaz N. van Marrewijk C. Buth J. Cuypers P. Duijm L. et al.Emergency treatment of acute symptomatic or ruptured abdominal aortic aneurysm Outcome of a prospective intent-to-treat by EVAR protocol.Eur J Vasc Endovasc Surg. 2003; 26: 303-310Abstract Full Text Full Text PDF PubMed Scopus (107) Google Scholar, 12Hinchliffe R.J. Bruijstens L. MacSweeney S.T. Braithwaite B.D. A randomized trial of endovascular and open surgery for ruptured abdominal aortic aneurysm—results of a pilot study and lessons learned for future studies.Eur J Vasc Endovasc Surg. 2006; 32: 506-515Abstract Full Text Full Text PDF PubMed Scopus (124) Google Scholar, 13Peppelenbosch N. Geelkerken R.H. Soong C. Cao P. Steinmetz O.K. Teijink J.A. et al.Endograft treatment of ruptured abdominal aortic aneurysms using the Talent aortouniiliac system: an international multicenter study.J Vasc Surg. 2006; 43: 1111-1123Abstract Full Text Full Text PDF PubMed Scopus (132) Google Scholar On the basis of these many reports, it is fair to say that the comparative efficacy of EVAR and open repair for RAAAs is controversial and that randomized, prospective comparative trials of the two treatment methods are needed with this entity. This article will show why this is not the case and why there is sufficient evidence without such trials to show that all RAAAs with anatomy suitable for EVAR should be treated in this way. EVAR has been used increasingly to treat patients with RAAAs and offers many theoretic advantages over open repair. It is less invasive, eliminates damage to periaortic and abdominal structures, decreases bleeding from surgical dissection, minimizes hypothermia, and lessens the requirement for deep anesthesia. Because of these potential advantages and reports of lower procedural mortality, EVAR has been deemed superior to open repair for the treatment of RAAAs.3Lachat M.L. Pfammatter T. Witzke H.J. Bettex D. Dunzli A. Wolfensberger U. et al.Endovascular repair with bifurcated stent-grafts under local anaesthesia to improve outcome of ruptured aortoiliac aneurysms.Eur J Vasc Endovasc Surg. 2002; 23: 528-536Abstract Full Text PDF PubMed Scopus (160) Google Scholar, 4Veith F.J. Ohki T. Endovascular approaches to ruptured infrarenal aorto-iliac aneurysms.J Cardiovasc Surg. 2002; 3: 369-378Google Scholar, 5Veith F.J. Lachat M. Mayer D. Malina M. Holst J. Mehta M. et al.Collected world and single center experience with endovascular treatment of ruptured abdominal aortic aneurysms.Ann Surg. 2009; 250: 818-824Crossref PubMed Scopus (128) Google Scholar, 6Hechelhammer L. Lachat M.L. Wildermuth S. Bettex D. Mayer D. Pfammatter T. Midterm outcome of endovascular repair of ruptured abdominal aortic aneurysms.J Vasc Surg. 2005; 41: 752-757Abstract Full Text Full Text PDF PubMed Scopus (125) Google Scholar, 7Mehta M. Darling III, R.C. Roddy S.P. Fecteau S. Ozsvath K.J. Kreienberg P.B. et al.Factors associated with abdominal compartment syndrome complicating endovascular repair of ruptured abdominal aortic aneurysms.J Vasc Surg. 2005; 42: 1047-1051Abstract Full Text Full Text PDF PubMed Scopus (113) Google Scholar, 8Coppi G. Silingardi R. Gennai S. Saitta G. Ciardullo A.V. A single centre experience in open and endovascular treatment of hemodynamically unstable and stable patients with ruptured abdominal aortic aneurysms.J Vasc Surg. 2006; 44: 1140-1147Abstract Full Text Full Text PDF PubMed Scopus (99) Google Scholar, 9Moore R. Nutley M. Cina C.S. Motamedi M. Faris P. Abuznadah W. Improved survival after introduction of an emergency endovascular therapy protocol for ruptured abdominal aortic aneurysms.J Vasc Surg. 2007; 45: 443-450Abstract Full Text Full Text PDF PubMed Scopus (150) Google Scholar, 10Mayer D. Pfammatter T. Rancic Z. Hechelhammer L. Wilhelm M. Veith F.J. et al.10 years of emergency endovascular aneurysm repair for ruptured abdominal aortoiliac aneurysms—lessons learned.Ann Surg. 2009; 249: 510-515Crossref PubMed Scopus (46) Google Scholar Between July 1, 2002, and January 15, 2009, data were collected from 49 centers around the world performing EVAR for RAAAs. Some of these data were from 13 centers that were committed to EVAR and performed this procedure on all or almost all RAAAs in patients who had suitable aortic neck and iliac artery anatomy for EVAR. The data from these 13 centers was updated to January 15, 2009.5Veith F.J. Lachat M. Mayer D. Malina M. Holst J. Mehta M. et al.Collected world and single center experience with endovascular treatment of ruptured abdominal aortic aneurysms.Ann Surg. 2009; 250: 818-824Crossref PubMed Scopus (128) Google Scholar The overall collected data with the use of EVAR to treat 1037 patients with a RAAA or a ruptured aortoiliac aneurysm show an overall 30-day mortality of 21.2%. This 30-day mortality is clearly less than the rate of 35% to 55% after open repair for RAAAs, as reported in multiple studies.14Bown M.J. Sutton A.J. Bell P.R. Sayers R.D. A meta-analysis of 50 years of ruptured abdominal aortic aneurysm repair.Br J Surg. 2002; 89: 714-730Crossref PubMed Scopus (281) Google Scholar In the collected experience, however, many of the centers limited the use of EVAR to “stable” RAAA patients or even those with “contained” ruptures. Because hemodynamic instability is associated with a higher risk of procedural mortality,6Hechelhammer L. Lachat M.L. Wildermuth S. Bettex D. Mayer D. Pfammatter T. Midterm outcome of endovascular repair of ruptured abdominal aortic aneurysms.J Vasc Surg. 2005; 41: 752-757Abstract Full Text Full Text PDF PubMed Scopus (125) Google Scholar, 8Coppi G. Silingardi R. Gennai S. Saitta G. Ciardullo A.V. A single centre experience in open and endovascular treatment of hemodynamically unstable and stable patients with ruptured abdominal aortic aneurysms.J Vasc Surg. 2006; 44: 1140-1147Abstract Full Text Full Text PDF PubMed Scopus (99) Google Scholar, 14Bown M.J. Sutton A.J. Bell P.R. Sayers R.D. A meta-analysis of 50 years of ruptured abdominal aortic aneurysm repair.Br J Surg. 2002; 89: 714-730Crossref PubMed Scopus (281) Google Scholar it is invalid to compare the lower procedural EVAR mortality rates with those for open repair. Because of this, the updated outcomes for EVAR were examined in the selected group of 13 centers that were committed to performing EVAR to treat all RAAA patients who were anatomically suitable for endograft treatment, including those that were hemodynamically unstable and those in profound shock.5Veith F.J. Lachat M. Mayer D. Malina M. Holst J. Mehta M. et al.Collected world and single center experience with endovascular treatment of ruptured abdominal aortic aneurysms.Ann Surg. 2009; 250: 818-824Crossref PubMed Scopus (128) Google Scholar These centers were usually the ones with the larger experience. Although there was some variability in the approach of these centers to the treatment of RAAA patients, most had some degree of standardization and many had a defined protocol. All were experienced in the use of EVAR and endovascular adjuncts for elective abdominal aneurysm treatment and all had dedicated endovascular facilities and imaging equipment. Despite the use of EVAR to treat almost all anatomically suitable RAAA patients, the 30-day mortality for EVAR in 680 patients was a favorable 19.7% (range, 0%-32%).5Veith F.J. Lachat M. Mayer D. Malina M. Holst J. Mehta M. et al.Collected world and single center experience with endovascular treatment of ruptured abdominal aortic aneurysms.Ann Surg. 2009; 250: 818-824Crossref PubMed Scopus (128) Google Scholar These same 13 centers performed open repair for RAAAs in 763 patients who had anatomy unsuitable for EVAR during this same period, and the 30-day mortality for open repair was 36.3% (range, 8%-49%; P < .0001 for EVAR vs open repair).5Veith F.J. Lachat M. Mayer D. Malina M. Holst J. Mehta M. et al.Collected world and single center experience with endovascular treatment of ruptured abdominal aortic aneurysms.Ann Surg. 2009; 250: 818-824Crossref PubMed Scopus (128) Google Scholar These updated comparative outcome results (30-day mortality 19.7% for EVAR vs 36.3% for open repair) from these 13 centers committed to EVAR treatment of all possible RAAAs strongly suggest that EVAR is a superior way to treat RAAAs in those patients who have aortic neck and iliac anatomy suitable for endovascular graft treatment. Additional proof that EVAR is a better treatment for some RAAA patients is that 10% to 15% of patients in this collected experience, who were categorically unsuitable or prohibitively high risk for open repair, survived for many years after EVAR.5Veith F.J. Lachat M. Mayer D. Malina M. Holst J. Mehta M. et al.Collected world and single center experience with endovascular treatment of ruptured abdominal aortic aneurysms.Ann Surg. 2009; 250: 818-824Crossref PubMed Scopus (128) Google Scholar There are several possible reasons that might explain the discordant results for RAAA treatment by EVAR reported by different authors.3Lachat M.L. Pfammatter T. Witzke H.J. Bettex D. Dunzli A. Wolfensberger U. et al.Endovascular repair with bifurcated stent-grafts under local anaesthesia to improve outcome of ruptured aortoiliac aneurysms.Eur J Vasc Endovasc Surg. 2002; 23: 528-536Abstract Full Text PDF PubMed Scopus (160) Google Scholar, 4Veith F.J. Ohki T. Endovascular approaches to ruptured infrarenal aorto-iliac aneurysms.J Cardiovasc Surg. 2002; 3: 369-378Google Scholar, 5Veith F.J. Lachat M. Mayer D. Malina M. Holst J. Mehta M. et al.Collected world and single center experience with endovascular treatment of ruptured abdominal aortic aneurysms.Ann Surg. 2009; 250: 818-824Crossref PubMed Scopus (128) Google Scholar, 6Hechelhammer L. Lachat M.L. Wildermuth S. Bettex D. Mayer D. Pfammatter T. Midterm outcome of endovascular repair of ruptured abdominal aortic aneurysms.J Vasc Surg. 2005; 41: 752-757Abstract Full Text Full Text PDF PubMed Scopus (125) Google Scholar, 7Mehta M. Darling III, R.C. Roddy S.P. Fecteau S. Ozsvath K.J. Kreienberg P.B. et al.Factors associated with abdominal compartment syndrome complicating endovascular repair of ruptured abdominal aortic aneurysms.J Vasc Surg. 2005; 42: 1047-1051Abstract Full Text Full Text PDF PubMed Scopus (113) Google Scholar, 8Coppi G. Silingardi R. Gennai S. Saitta G. Ciardullo A.V. A single centre experience in open and endovascular treatment of hemodynamically unstable and stable patients with ruptured abdominal aortic aneurysms.J Vasc Surg. 2006; 44: 1140-1147Abstract Full Text Full Text PDF PubMed Scopus (99) Google Scholar, 9Moore R. Nutley M. Cina C.S. Motamedi M. Faris P. Abuznadah W. Improved survival after introduction of an emergency endovascular therapy protocol for ruptured abdominal aortic aneurysms.J Vasc Surg. 2007; 45: 443-450Abstract Full Text Full Text PDF PubMed Scopus (150) Google Scholar, 10Mayer D. Pfammatter T. Rancic Z. Hechelhammer L. Wilhelm M. Veith F.J. et al.10 years of emergency endovascular aneurysm repair for ruptured abdominal aortoiliac aneurysms—lessons learned.Ann Surg. 2009; 249: 510-515Crossref PubMed Scopus (46) Google Scholar, 11Peppelenbosch N. Yilmaz N. van Marrewijk C. Buth J. Cuypers P. Duijm L. et al.Emergency treatment of acute symptomatic or ruptured abdominal aortic aneurysm Outcome of a prospective intent-to-treat by EVAR protocol.Eur J Vasc Endovasc Surg. 2003; 26: 303-310Abstract Full Text Full Text PDF PubMed Scopus (107) Google Scholar, 12Hinchliffe R.J. Bruijstens L. MacSweeney S.T. Braithwaite B.D. A randomized trial of endovascular and open surgery for ruptured abdominal aortic aneurysm—results of a pilot study and lessons learned for future studies.Eur J Vasc Endovasc Surg. 2006; 32: 506-515Abstract Full Text Full Text PDF PubMed Scopus (124) Google Scholar, 13Peppelenbosch N. Geelkerken R.H. Soong C. Cao P. Steinmetz O.K. Teijink J.A. et al.Endograft treatment of ruptured abdominal aortic aneurysms using the Talent aortouniiliac system: an international multicenter study.J Vasc Surg. 2006; 43: 1111-1123Abstract Full Text Full Text PDF PubMed Scopus (132) Google Scholar Among these reasons is the importance of several strategies, adjuncts, and technical factors that are thought to influence the outcome of EVAR treatment for RAAAs and which probably account for the favorable EVAR outcomes in the 13 centers in the collected experience committed to perform EVAR whenever possible5Veith F.J. Lachat M. Mayer D. Malina M. Holst J. Mehta M. et al.Collected world and single center experience with endovascular treatment of ruptured abdominal aortic aneurysms.Ann Surg. 2009; 250: 818-824Crossref PubMed Scopus (128) Google Scholar: These allow the most effective decision making and treatment of these patients in what are often confusing and stressful circumstances.9Moore R. Nutley M. Cina C.S. Motamedi M. Faris P. Abuznadah W. Improved survival after introduction of an emergency endovascular therapy protocol for ruptured abdominal aortic aneurysms.J Vasc Surg. 2007; 45: 443-450Abstract Full Text Full Text PDF PubMed Scopus (150) Google Scholar, 10Mayer D. Pfammatter T. Rancic Z. Hechelhammer L. Wilhelm M. Veith F.J. et al.10 years of emergency endovascular aneurysm repair for ruptured abdominal aortoiliac aneurysms—lessons learned.Ann Surg. 2009; 249: 510-515Crossref PubMed Scopus (46) Google Scholar They are also important to facilitate education in and recognition of RAAAs by generalists, emergency department personnel, and others to enable early diagnosis and mobilization of the specialized care givers best trained to optimize treatment. Fluid resuscitation should be restricted, even if the patient becomes hypotensive. Experience has shown that systolic arterial pressures of 50 to 70 mm Hg are well tolerated for short periods and limit internal bleeding and its associated loss of platelets and clotting factors.4Veith F.J. Ohki T. Endovascular approaches to ruptured infrarenal aorto-iliac aneurysms.J Cardiovasc Surg. 2002; 3: 369-378Google Scholar, 5Veith F.J. Lachat M. Mayer D. Malina M. Holst J. Mehta M. et al.Collected world and single center experience with endovascular treatment of ruptured abdominal aortic aneurysms.Ann Surg. 2009; 250: 818-824Crossref PubMed Scopus (128) Google Scholar, 6Hechelhammer L. Lachat M.L. Wildermuth S. Bettex D. Mayer D. Pfammatter T. Midterm outcome of endovascular repair of ruptured abdominal aortic aneurysms.J Vasc Surg. 2005; 41: 752-757Abstract Full Text Full Text PDF PubMed Scopus (125) Google Scholar, 10Mayer D. Pfammatter T. Rancic Z. Hechelhammer L. Wilhelm M. Veith F.J. et al.10 years of emergency endovascular aneurysm repair for ruptured abdominal aortoiliac aneurysms—lessons learned.Ann Surg. 2009; 249: 510-515Crossref PubMed Scopus (46) Google Scholar, 15van der Vliet J.A. van Aalst D.L. Schultze Kool L.J. Wever J.J. Blankensteijn J.D. Hypotensive hemostasis (permissive hypotension) for ruptured abdominal aortic aneurysm: are we really in control?.Vascular. 2007; 15: 197-200Crossref PubMed Scopus (40) Google Scholar Whether pharmacologic lowering of blood pressure is beneficial remains to be conclusively shown.6Hechelhammer L. Lachat M.L. Wildermuth S. Bettex D. Mayer D. Pfammatter T. Midterm outcome of endovascular repair of ruptured abdominal aortic aneurysms.J Vasc Surg. 2005; 41: 752-757Abstract Full Text Full Text PDF PubMed Scopus (125) Google Scholar, 10Mayer D. Pfammatter T. Rancic Z. Hechelhammer L. Wilhelm M. Veith F.J. et al.10 years of emergency endovascular aneurysm repair for ruptured abdominal aortoiliac aneurysms—lessons learned.Ann Surg. 2009; 249: 510-515Crossref PubMed Scopus (46) Google Scholar EVAR procedures are optimally performed in a site equipped for excellent fluoroscopic imaging and open surgery, because some patients will require open repair or open adjuncts to their EVAR. The latter should be obtained percutaneously under local anesthesia. This permits arteriography to define aortic and arterial anatomy, facilitates large sheath and supraceliac balloon placement if needed, and prevents circulatory collapse caused by the induction of general anesthesia. Whether general anesthesia is used later to eliminate motion and improve fluoroscopic imaging to permit precise graft deployment remains controversial. One group has successfully used local anesthesia supplemented by sedation throughout as an alternative.3Lachat M.L. Pfammatter T. Witzke H.J. Bettex D. Dunzli A. Wolfensberger U. et al.Endovascular repair with bifurcated stent-grafts under local anaesthesia to improve outcome of ruptured aortoiliac aneurysms.Eur J Vasc Endovasc Surg. 2002; 23: 528-536Abstract Full Text PDF PubMed Scopus (160) Google Scholar, 6Hechelhammer L. Lachat M.L. Wildermuth S. Bettex D. Mayer D. Pfammatter T. Midterm outcome of endovascular repair of ruptured abdominal aortic aneurysms.J Vasc Surg. 2005; 41: 752-757Abstract Full Text Full Text PDF PubMed Scopus (125) Google Scholar, 10Mayer D. Pfammatter T. Rancic Z. Hechelhammer L. Wilhelm M. Veith F.J. et al.10 years of emergency endovascular aneurysm repair for ruptured abdominal aortoiliac aneurysms—lessons learned.Ann Surg. 2009; 249: 510-515Crossref PubMed Scopus (46) Google Scholar Most groups favor their use only when there is severe circulatory collapse. In such cases, deflation of the balloon before sealing of the rupture site will result in immediate recurrence of the circulatory collapse. Therefore, techniques have been developed to maintain continuous aortic control until the endograft has sealed the leak.4Veith F.J. Ohki T. Endovascular approaches to ruptured infrarenal aorto-iliac aneurysms.J Cardiovasc Surg. 2002; 3: 369-378Google Scholar, 5Veith F.J. Lachat M. Mayer D. Malina M. Holst J. Mehta M. et al.Collected world and single center experience with endovascular treatment of ruptured abdominal aortic aneurysms.Ann Surg. 2009; 250: 818-824Crossref PubMed Scopus (128) Google Scholar, 6Hechelhammer L. Lachat M.L. Wildermuth S. Bettex D. Mayer D. Pfammatter T. Midterm outcome of endovascular repair of ruptured abdominal aortic aneurysms.J Vasc Surg. 2005; 41: 752-757Abstract Full Text Full Text PDF PubMed Scopus (125) Google Scholar, 10Mayer D. Pfammatter T. Rancic Z. Hechelhammer L. Wilhelm M. Veith F.J. et al.10 years of emergency endovascular aneurysm repair for ruptured abdominal aortoiliac aneurysms—lessons learned.Ann Surg. 2009; 249: 510-515Crossref PubMed Scopus (46) Google Scholar, 16Malina M. Veith F. Ivancev K. Sonesson B. Balloon occlusion of the aorta during endovascular repair of ruptured abdominal aortic aneurysm.J Endovasc Ther. 2005; 12: 556-559Crossref PubMed Scopus (45) Google Scholar, 17Larzon T. Lindgren R. Norgren L. Endovascular treatment of RAAAs: a shift of the paradigm.J Endovasc Ther. 2005; 12: 548-555Crossref PubMed Scopus (99) Google Scholar These techniques use multiple balloons to minimize renal and visceral ischemia by placing secondary balloons within the endograft as the supraceliac balloon is deflated and removed through its supporting sheath. Bifurcated and aortouniiliac (or femoral) grafts can both be used successfully, although some patients have unilateral iliac disease that mandates a unilateral configuration. Modular and unibody grafts have been used successfully in both configurations. An appropriate inventory of suitable grafts and accessories must be stocked sterile in the treatment site and be available for the procedure and unexpected contingencies. Abdominal compartment syndr" @default.
• W2093008737 created "2016-06-24" @default.
• W2093008737 creator A5000539614 @default.
• W2093008737 creator A5040632378 @default.
• W2093008737 creator A5048078586 @default.
• W2093008737 date "2010-10-01" @default.
• W2093008737 modified "2023-09-26" @default.
• W2093008737 title "Is a randomized trial necessary to determine whether endovascular repair is the preferred management strategy in patients with ruptured abdominal aortic aneurysms?" @default.
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