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Endovascular treatment for ruptured abdominal aortic aneurysm

  • Review
  • Intervention




An abdominal aortic aneurysm (AAA) (the pathological enlargement of the aorta) can develop in both men and women as they grow older. It is most commonly seen in men over the age of 65 years. Progressive aneurysm enlargement can lead to rupture and massive internal bleeding, a fatal event unless timely repair can be achieved. Despite improvements in perioperative care, mortality remains high (approximately 50%) after conventional open surgical repair. A newer minimally invasive technique, endovascular repair, has been shown to reduce early morbidity and mortality, as compared to conventional open surgery, for planned AAA repair. Emergency endovascular repair (eEVAR) has been used successfully to treat ruptured abdominal aortic aneurysm (RAAA), proving that it is feasible in selected patients. However, it is not yet known if eEVAR will lead to significant improvements in outcomes for these patients or indeed if it can replace conventional open repair as the preferred treatment for this lethal condition.


To compare the advantages and disadvantages of eEVAR in comparison with conventional open surgical repair for the treatment of RAAA.

Search methods

The Cochrane Peripheral Vascular Diseases Group searched their trials register (last searched 30 October 2006) and the Cochrane Central Register of Controlled Trials (CENTRAL) database (last searched Issue 4, 2006). We searched a number of electronic databases and handsearched relevant journals until March 2006 to identify studies for inclusion.

Selection criteria

Randomised controlled trials in which patients with a confirmed ruptured abdominal aortic aneurysm were randomly allocated to eEVAR, or conventional open surgical repair.

Data collection and analysis

Studies identified for potential inclusion were independently assessed for eligibility by at least two reviewers, with excluded studies further checked by the agreed arbitrators. As no randomised controlled trials were identified at present no tests of heterogeneity or sensitivity analysis were performed.

Main results

There were no randomised controlled trials identified at present comparing eEVAR with conventional open surgical repair for the treatment of RAAA.

Authors' conclusions

There is no high quality evidence to support the use of eEVAR in the treatment of RAAA. However, evidence from prospective controlled studies without randomisation, prospective studies, and retrospective case series suggest that eEVAR is feasible in selected patients, with outcomes comparable to best conventional open surgical repair for the treatment of RAAA. Furthermore, endovascular repair in selected patients may be associated with a trend towards reductions in blood loss, duration of intensive care treatment, and mortality.

Plain language summary

Endovascular repair for ruptured abdominal aortic aneurysm

The abdominal aorta is the main artery supplying blood to the lower part of the body. An abnormal ballooning and weakening of the wall of the aorta (aortic aneurysm) particularly affects men as they grow older. An aneurysm may progressively enlarge without obvious symptoms yet it is potentially lethal as the aneurysm can burst (rupture) causing massive internal bleeding. Death is inevitable unless the bleeding can be stopped and blood flow to the lower body restored promptly. Until recently this required an open operation (laparotomy) to clamp the abdominal aorta and replace the segment of the aorta with a synthetic artery tube-graft. Many patients do not survive this major operation due to the effects of massive bleeding or failure of vital organs, such as the heart, lungs, and kidneys despite improvements in surgical technique and care of the critically ill patient.

A recent minimally invasive technique, termed endovascular repair, allows the surgeon to pass a stent graft through the blood vessels from the groin to the site of rupture where it is positioned, attached to healthy artery above and below the aneurysm to stop bleeding and form a new channel for blood flow. This technique is successful in suitable patients for the planned treatment of non-ruptured aneurysms and can reduce early post-operative complications and deaths. The present review looked at the available evidence for its effectiveness compared with open surgery for ruptured aneurysms. The review authors searched the medical literature but found no completed randomised controlled trial. Evidence from case series, 10 prospective and 21 retrospective reports, indicates that emergency endovascular repair is feasible and may reduce blood loss, duration of stay in intensive care and deaths in selected patients. These reports were from vascular surgery centres with considerable experience of the technique.