Commentary: Why Open Surgical Repair Still Matters—The Importance of Protocol-Driven Management for Ruptured Abdominal Aortic Aneurysm

Abstract

See Article page 185.

Ruptured abdominal aortic aneurysm (rAAA) remains among the most lethal vascular surgical emergencies, with overall mortality exceeding 80% when pre-hospital deaths are included [1]. In this context, the recent single-center study by Kim et al. [2], published in the Journal of Chest Surgery, represents a timely and clinically meaningful contribution. By reaffirming the effectiveness of open surgical repair (OSR) across a range of anatomical presentations, the study underscores the enduring relevance of OSR, even as endovascular approaches gain popularity.

A particularly significant finding of this study is that more than half of patients were deemed anatomically unsuitable for emergency endovascular aneurysm repair (eEVAR). This highlights well-known anatomical challenges prevalent in Asian populations, especially among Korean patients, such as short proximal necks, hostile angulation, or narrow iliac arteries, all of which may preclude the use of EVAR [3]. Additionally, the substantial improvement in clinical outcomes observed after the establishment of a dedicated aortic surgical team emphasizes that expertise and systemic organization are crucial in improving survival. Since 2017, the study reports a marked reduction in 30-day mortality following OSR, indicating that specialization and structured care delivery can be as decisive as surgical technique itself.

At Ewha Womans University Seoul Hospital, we implemented a fast-track protocol for managing rAAA as early as 2011. This protocol includes immediate acceptance of referrals, pre-arrival computed tomography (CT) image review via mobile device, direct transfer to the operating room bypassing the emergency department, complete surgical draping prior to anesthesia, omission of systemic heparinization, preferential use of I-grafts, and the use of an open abdomen strategy when abdominal compartment syndrome is suspected. All procedures are carried out by a fixed surgical and anesthesia team, ensuring consistency and efficiency throughout the care process.

Within this framework, our institutional outcomes for OSR have been highly encouraging, even when benchmarked against international standards [4]. As of May 2023, we had performed 236 OSRs for rAAA, with 13 deaths occurring within 30 days, yielding a 30-day mortality rate of 5.5%. This result is notably superior to most published OSR outcomes. Importantly, our patient cohort included a significant proportion of individuals presenting with severe shock or preoperative cardiac arrest, further highlighting the protocol’s effectiveness. While our findings have not yet been formally published, they have been presented in abstract form and reflect the significant impact of a systematized, protocol-driven approach to treatment.

Through an analysis of our own data, we identified preoperative cardiac arrest, hypotensive shock, and a history of stroke as the strongest predictors of mortality. Notably, factors such as transfer distance or door-to-incision time were not independently associated with mortality. This suggests that coordinated preparedness—rather than speed alone—plays a more decisive role in determining patient survival.

While enthusiasm for eEVAR continues to grow, we urge caution against overreliance on this strategy. Multiple randomized controlled trials, including ECAR, AJAX, and IMPROVE, have failed to demonstrate a clear survival benefit for eEVAR over OSR [5-7]. A patient-level meta- analysis of these trials similarly did not find statistically significant advantages for eEVAR [8]. Furthermore, off-label use of EVAR that violates device instructions for use has been linked to higher rates of endoleak, reintervention, and intraoperative conversion to OSR [9]. In practical settings, particularly in centers unable to maintain a full inventory of stent graft sizes, eEVAR may result in delays in hemorrhage control and increased technical complexity.

Given these considerations, the paradigm for rAAA management should move beyond a binary “EVAR versus OSR” framework, instead adopting a comprehensive, protocolized approach involving multidisciplinary teams. In our model, the operating room is fully prepared before the patient arrives, CT images are reviewed in real time via mobile devices, and surgical-anesthetic coordination is conducted seamlessly in a single, integrated workflow. The emphasis is not only on the choice of technique, but on the overall efficiency and readiness of the system.

Furthermore, national surgical registries must evolve to capture qualitative metrics that go beyond procedural labels. These should include center volume, the existence of fast-track protocols, the availability of dedicated aortic teams, and average aortic clamp times. Such factors are likely to have a greater impact on patient outcomes than the specific procedure performed.

In summary, the study by Kim et al. [2] provides compelling evidence that OSR remains a vital and effective option in the contemporary management of rAAA. Their findings reinforce the principle that, when performed by experienced surgeons within a well-organized system, OSR can produce outcomes comparable to, or even better than, those of eEVAR. We commend the authors for this important contribution and hope their work encourages wider adoption of structured, protocol-driven OSR systems in the treatment of rAAA.

Funding Statement

Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.