A Population Based Study of Post-EVAR Rupture during 15 years.

Abstract Objective The devastating event of a ruptured abdominal aortic aneurysm (AAA) in patients who have survived a previous AAA repair, either elective or urgent, is a feared and quite uncommon event. It has been suggested to partly explain the loss of the early survival benefit for EndoVascular Aortic Repair (EVAR) versus Open Surgical Repair (OSR). The main objective of this study was to report the national incidence rate, risk factors and outcome of post-EVAR ruptures. Secondarily, the national incidence rate of ruptures following OSR (post-OSR ruptures) was investigated. Methods A nationwide, population-based, retrospective cohort study utilizing the in- and outpatient entries for all patients >40 years of age, receiving their first (index) surgical procedure for AAA, from 2001 to 2015. Only patients surviving their index procedure were included. The primary outcome was ruptured AAA (rAAA), registered after discharge from the index procedure (EVAR or OSR), identified in the Swedish National Patient Registry (NPR) and the Cause of Death Registry (CDR). Results In total, 14859 patients survived their primary (index) AAA procedure. There were 6470 EVAR procedures, 5893 for intact AAA (iAAA) and 577 for rAAA were identified. Of the 6470 EVAR patients, 86 cases of post-EVAR rupture were identified, corresponding to a cumulative incidence of 1.3% over a mean follow-up time of 3.9 years. The incidence rate was 3.4 (95% CI 2.7-4.2)/1000 person years (py). The independent risk factors identified for post-EVAR rupture were rAAA at index surgery HR 2.4 (95% CI 1.4-4.1, p 0.002) and age HR 1.1 (95% CI 1.0-1.1, p Conclusion Post-EVAR rupture is a rare complication, which can occur at any time after the index EVAR procedure. This may have implications for the discussion of limited follow-up programs and for the choice of procedure in AAA patients with long life expectancy. rAAA as indication for the index surgery and age were identified as risk factors for post-EVAR rupture. Mortality of post-EVAR rupture is high, but lower than that of primary rAAA. The much lower risk of post-OSR rupture was confirmed but must not be neglected as a possible late complication.