Aneurysm rupture after EVAR: can the ultimate failure be predicted?

Objectives: To provide insight into the causes and timing of AAA rupture after EVAR.

Design: Original data regarding AAA ruptures following EVAR were collected from MEDLINE and EMBASE databases. Data were extracted systematically and patient and procedural characteristics were analyzed.

Results: 270 patients with AAA ruptures after EVAR were identified. Causes of rupture included endoleaks (in 160: type IA 57, type IB 31, type II 23, type III 26, type IV 0, endotension 9, unspecified 14), graft migration 41, graft disconnection 11 and infection 6. Most of the described AAA ruptures occurred within 2-3 years after EVAR. Mean initial AAA diameter was relatively large (65 mm). No abnormalities were present in 41 patients during follow-up before rupture. Structural graft failure was described in 96 and a fatal course in 119 patients.

Conclusions: Focus of surveillance on the first 2-3 years after EVAR may possibly reduce the AAA rupture rate, especially in patients with increased risk of early rupture (relatively large initial AAA diameter or presence of endoleak or graft migration). Better stent-graft durability and longevity is required to further reduce the AAA rupture risk after EVAR. Complete prevention will however remain challenging since AAA rupture may occur even if no predisposing abnormalities are present.