Prehospital Considerations for REVAR

Abstract

Ruptured abdominal aortic aneurysms (rAAA) are associated with a high rate of mortality, ranging from 30 to 80 % [1]. These rates most likely underestimate the overall death rate since considerable numbers of these patients die from free rupture prior to presenting to the hospital [2]. As experience with elective endovascular aneurysm repair (EVAR) has grown, it was inevitable that its use would be considered and studied in the ruptured setting, where open abdominal aortic aneurysm repair was the reigning gold standard. Since elective EVAR had been associated with reduced perioperative morbidity and mortality, and results of open repair of ruptured AAAs had not significantly improved over the past several decades, several institutions initiated programs of EVAR for ruptured AAAs (REVAR) to evaluate whether the EVAR advantages extended to the ruptured state. Recent reports of such single institution series have shown that endovascular repair of ruptured abdominal aortic aneurysms led to both lower mortality and morbidity rates, suggesting that it becomes the standard of care for patients with ruptured infrarenal abdominal aortic aneurysms with suitable anatomy [3, 4]. The recently published results of the IMPROVE trial reported no improvement in outcomes, other than discharge to home, for patients randomized to the REVAR strategy group [5]. However, analysis per treatment received rather than by strategy assigned revealed 30-day mortality rates of 26 % for REVAR and 37 % for open repair [6]. Reports such as these, showing REVAR to be at least as effective as open repair, coupled with increasing operator experience with aortic endografting have resulted in more surgeons having attained a level of comfort that allows them to consider adding REVAR to their therapeutic armamentarium. However, optimal outcomes from REVAR come not only from an isolated competent surgeon but also from a system of care that focuses on rapid diagnosis, permissive hypotension while awaiting treatment or during patient transfer, and therapy customized to the patient’s anatomy and coexisting conditions.