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Published on February 14, 2014

Crozer Research Supports Less Invasive Approach for Emergency Aneurysm Repair 

In Brief

  • An abdominal aortic aneurysm (AAA, or “triple A”) occurs when the walls of the large blood vessel (aorta) that supplies the lower half of the body balloon outward. Roughly 85 percent of patients die after a ruptured AAA, and only about one-third make it to the hospital.
  • A ruptured AAA can be repaired with a cylindrical graft placed through a long open incision or through an endovascular procedure, in which surgeons access the aorta through the femoral artery and use a stent to place the graft.
  • Studies from major university centers have shown reductions in mortality with the use of endovascular repair, but some experts have suggested that this benefit would not be as significant in community settings.
  • Results of research by Crozer-Chester Medical Center vascular surgeons suggest that community-based hospitals experienced in the endovascular repair of AAAs should use that technique for elective or emergency surgery. 

Gregory Domer

Gregory Domer,
M.D.

An abdominal aortic aneurysm (AAA, or “triple A”) occurs when the walls of the large blood vessel (aorta) that supplies the lower half of the body balloon outward. If the aneurysm ruptures, time is of the essence: Blood spills into the abdominal cavity and the situation quickly turns life-threatening. Roughly 85 percent of patients die after a ruptured AAA, and only about one-third make it to the hospital. 

A ruptured AAA can be repaired with a cylindrical graft placed through a long open incision, which entails significant risks and recovery time, or through a less invasive endovascular procedure, in which surgeons access the aorta through the femoral artery and use a stent to place the graft. Although endovascular repair has been around for 20 years and is frequently used for elective repair of AAAs at high risk of rupture, it is not yet in widespread use for ruptured AAAs. The thinking was that only large academic medical centers see enough of these emergency cases to be able to do the procedure effectively. Studies from major university centers have shown reductions in mortality with the use of endovascular repair, but some experts have suggested that the mortality benefit would not be as significant in community settings. 

Now, new research by a team of Crozer-Chester Medical Center vascular surgeons has questioned that assumption. The results, which were presented at the November 2013 conference of the Annual Clinical Assembly of Osteopathic Surgeons in Las Vegas, suggest that community-based hospitals experienced in the endovascular repair of AAAs should use that technique, whether for elective or emergency surgery. The team included Gregory Domer, MD, chief of the Division of Vascular Surgery and Endovascular Intervention; fellow Carmen Piccolo, DO; and residents Marissa Famularo, DO, and Nicholas Madden, DO, both of the Philadelphia College of Osteopathic Medicine. 

“Nationally, about 60 to 65 percent of all aneurysms are repaired endovascularly, but only about 15 to 20 percent of ruptured aneurysms are,” Domer says. “Our thinking was that if you have robust experience with performing endovascular repair in an elective situation, you can translate that into providing it for patients with ruptured aneurysms—even though you may only have a handful of them each year.” 

The researchers reviewed the cases of 59 patients who presented to Crozer’s Emergency Department with ruptured AAAs between 2007 and 2013. Of the 38 patients who made it to surgery, nine had endovascular repair and 29 had the much larger open incision. The results were striking: mortality after endovascular repair was 11.1 percent, versus 62.1 percent after open repair. In addition, the rate of complications was 11.1 percent versus 75.9 percent, respectively. 

“For patients having open repair, the recovery time is long: as much as four to six weeks for elective cases and even longer for ruptured aneurysms. But endovascular patients often leave the hospital the next day or within a few days,” notes Domer. “This research confirms that even with a small volume of ruptured AAAs, the endovascular approach is the better choice for institutions like ours, as we can draw on our experience with elective repair in these situations. 

“This research has resulted in a complete paradigm shift for Crozer-Chester Medical Center,” he adds. “Every patient who comes through the door with a suspected ruptured aneurysm is evaluated with a CAT scan as a possible candidate for endovascular repair.” 

Before starting to use endovascular repair to treat ruptured abdominal aortic aneurysms, Domer had treated nearly 400 at-risk aneurysms with the technique.

Certain factors, such as the position of the aneurysm relative to the kidneys, can make endovascular repair too difficult. Open surgical repair is still an option in such cases, but for most patients, the less invasive procedure is the better choice. Domer points out that patients with other significant health problems often did not do well with open surgical repair or refused the surgery entirely, so endovascular repair presents an exciting new option for them.

“This is a game-changer,” he says. “Now we can offer this advanced technique even in the most complex cases. This research gave us the confidence to make endovascular repair our standard of care whenever possible.” 

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