J.J. Reimerink

Endovascular repair versus open repair of ruptured abdominal aortic aneurysms: a multicenter randomized controlled trial.

Objective: Randomized comparison of endovascular repair (EVAR) with open repair (OR) in patients with a ruptured abdominal aortic aneurysm (RAAA). Background: Despite advances in operative technique and perioperative management RAAA remains fraught with a high rate of death and complications. Outcome may improve with a minimally invasive surgical technique: EVAR. Methods: All patients with a RAAA in the larger Amsterdam area were identified. Logistics for RAAA patients was changed with centralization of care in 3 trial centers. Patients both fit for EVAR and for OR were randomized to either of the treatments. Nonrandomized patients were followed in a prospective cohort. Primary endpoint of the study was the composite of death and severe complications at 30 days. Results: Between April 2004 and February 2011, we identified 520 patients with a RAAA of which 116 could be randomized. The primary endpoint rate for EVAR was 42% and for OR was 47% [absolute risk reduction (ARR) = 5.4%; 95% confidence interval (CI): −13% to +23%]. The 30-day mortality was 21% in patients assigned to EVAR compared with 25% for OR (ARR = 4.4% 95% CI: −11% to +20%). The mortality of all surgically treated patients in the nonrandomized cohort was 30% (95% CI: 26%–35%) and 26% (95% CI: 20% to 32%) in patients with unfavorable anatomy for EVAR, treated by OR at trial centers. Conclusions: This trial did not show a significant difference in combined death and severe complications between EVAR and OR. Mortality for OR both in randomized patients and in cohort patients was lower than anticipated, which may be explained by optimization of logistics, preoperative CT imaging, and centralization of care in centers of expertise.

Systematic review and meta‐analysis of population‐based mortality from ruptured abdominal aortic aneurysm

A substantial proportion of patients with a ruptured abdominal aortic aneurysm (rAAA) die outside hospital. The objective of this study was to estimate the total mortality, including prehospital deaths, of patients with rAAA.

Controlled Hypotension in Patients Suspected of a Ruptured Abdominal Aortic Aneurysm: Feasibility during Transport by Ambulance Services and Possible Harm

OBJECTIVE To evaluate a controlled hypotension protocol for patients suspected of a ruptured aneurysm of the abdominal aorta (RAAA) and to identify possible harm to patients with a final diagnosis other than RAAA. DESIGN Retrospective analysis of patients suspected of RAAA and transported by Amsterdam ambulance services between January 2006 and October 2007. PATIENTS AND METHODS Protocol was assessed by reviewing systolic blood pressure (<80 mmHg, 80-100 mmHg or >100 mmHg), administered fluid volume and verbal responsiveness during transport. Patients who could possibly have been harmed by controlled hypotension were identified by final diagnoses. RESULTS Fluid administration was according to protocol in 220 of 266 patients analysed for protocol adherence. The remaining patients received too much (21 patients) or too little fluid (25 patients). Data were missing in 29 patients. A RAAA was diagnosed in 81 (27%) of all 295 patients analysed for final diagnosis. Controlled hypotension was achieved in 10% of all patients and in 17% of patients with RAAA. Three patients (1%) with diagnosis other than RAAA were possibly at risk by implementing controlled hypotension. CONCLUSIONS Protocol was followed in 83% and protocol violations occurred in 17% of patients. The risk of implementing controlled hypotension for all patients suspected of an RAAA by the ambulance staff was low.

Effect of regional cooperation on outcomes from ruptured abdominal aortic aneurysm

Care for patients with a ruptured abdominal aortic aneurysm (rAAA) in the Amsterdam ambulance region (The Netherlands) was concentrated into vascular centres with a 24‐h full emergency vascular service in cooperation with seven referring regional hospitals. Previous population‐based survival after rAAA in the Netherlands was 46 (95 per cent confidence interval (c.i.) 43 to 49) per cent. It was hypothesized that regional cooperation would improve survival.