Surgery for ruptured abdominal aortic aneurysmBMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g95 (Published 13 January 2014) Cite this as: BMJ 2014;348:g95
- Martin Björck, professor of vascular surgery
- 1Department of Surgical Sciences, Uppsala University, SE-75185 Uppsala, Sweden
Two therapeutic alternatives exist in a patient with ruptured abdominal aortic aneurysm: immediate open repair or imaging with computed tomography followed by endovascular aneurysm repair if anatomically possible or open repair if not. The main advantage of the immediate open repair strategy is that further imaging is not required, and speed may save life. Endovascular repair, on the other hand, is less invasive and can in most cases be done under local anaesthesia, avoiding the life threatening severe hypotension associated with general anaesthesia in a bleeding patient.
Here is a situation of true equipoise. Observational research from Switzerland suggests that both strategies give equally excellent results,1 2 and two small randomised controlled trials failed to show any difference in mortality.3 4 In a linked paper (doi:10.1136/bmj.f7661), Powell and colleagues report the results of the IMPROVE trial,5 a major scientific achievement. Conducting a large trial in this emergent situation is demanding, not least because informed consent can be difficult to obtain. The Mental Capacity Act makes randomising patients in the United Kingdom without informed consent possible, which is ethically sound when the patient has potentially life threatening hypotension, …