Treatment of Ruptured Abdominal Aortic Aneurysms

The incidence of Abdominal Aortic Aneurysms (AAA) has persistently increased over the past decades (Best et al., 2003). This is partly attributed to increased ageing of the population, improved diagnostic tools and the introduction of screening programmes (Sakalihasan et al., 2005). To date, AAAs are responsible for 1.3% of all deaths among men aged between 65-85 years in developed countries (Sakalihasan et al., 2005). This percentage is probably even higher due to underestimation of AAA related mortality, since AAAs generally exist without symptoms (Acosta et al., 2006). In patients with an identified AAA and abdominal and/or back pain in combination with pain at palpation of the aneurysm (a so called symptomatic AAA), pending rupture of the AAA is assumed. However, evidence for a symptomatic AAA representing pending rupture is lacking (Scott et al., 2005). When rupture occurs, the mortality rate is as high as 80% (Semmens et al., 2000; Veith et al., 2003; Gorham et al., 2004). Forty percent of the patients with a ruptured AAA do not reach the hospital alive (Semmens et al., 2000) and in patients reaching the hospital and undergoing surgery, the mortality rate is approximately 50% (Sayers et al., 1997). Despite progression in surgical techniques, anaesthetical management, vascular prostheses and perioperative care, there is only a gradual decline in operative mortality rate over the past decades (Heller et al., 2000; Bown et al., 2002). In 1991, a new minimally invasive technique was described by Parodi et al. to treat AAA, endovascular aneurysm repair (EVAR) (Parodi et al., 1991). In the elective setting, EVAR showed an absolute and relative mortality risk reduction of approximately 3 and 75%, respectively (Prinssen et al., 2004; EVAR-trial-participants 2005). In the acute setting, emergency EVAR (eEVAR) is a strategy that might allow for improvement in above mentioned poor prognosis. Since 1994 an increasing amount of publications of eEVAR to treat acute AAAs is published. Currently, eEVAR has become an accepted treatment option which is increasingly being performed to treat acute AAA. However, the potential reduction in peri-operative mortality of eEVAR compared to conventional open repair in patients with an acute AAA is still open to debate. in this chapter, we will discuss the role of endovascular AAA repair in patients with a ruptured AAA.