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The effect of aortic morphology on peri-operative mortality of ruptured abdominal aortic aneurysm

IMPROVE Trial Investigators


IMPROVE Trial Investigators



Aims To investigate whether aneurysm shape and extent, which indicate whether a patient with ruptured abdominal aortic aneurysm (rAAA) is eligible for endovascular repair (EVAR), influence the outcome of both EVAR and open surgical repair. Methods and results The influence of six morphological parameters (maximum aortic diameter, aneurysm neck diameter, length and conicality, proximal neck angle, and maximum common iliac diameter) on mortality and reinterventions within 30 days was investigated in rAAA patients randomized before morphological assessment in the Immediate Management of the Patient with Rupture: Open Versus Endovascular strategies (IMPROVE) trial. Patients with a proven diagnosis of rAAA, who underwent repair and had their admission computerized tomography scan submitted to the core laboratory, were included. Among 458 patients (364 men, mean age 76 years), who had either EVAR (n = 177) or open repair (n = 281) started, there were 155 deaths and 88 re-interventions within 30 days of randomization analysed according to a pre-specified plan. The mean maximum aortic diameter was 8.6 cm. There were no substantial correlations between the six morphological variables. Aneurysm neck length was shorter in those undergoing open repair (vs. EVAR). Aneurysm neck length (mean 23.3, SD 16.1 mm) was inversely associated with mortality for open repair and overall: adjusted OR 0.72 (95% CI 0.57, 0.92) for each 16 mm (SD) increase in length. There were no convincing associations of morphological parameters with reinterventions. Conclusion Short aneurysm necks adversely influence mortality after open repair of rAAA and preclude conventional EVAR. This may help explain why observational studies, but not randomized trials, have shown an early survival benefit for EVAR.


IMPROVE Trial Investigators. (2015). The effect of aortic morphology on peri-operative mortality of ruptured abdominal aortic aneurysm. European Heart Journal, 36(21), 1328-1334.

Journal Article Type Article
Acceptance Date Dec 22, 2014
Online Publication Date Jan 27, 2015
Publication Date Jun 1, 2015
Deposit Date Mar 9, 2017
Publicly Available Date Mar 9, 2017
Journal European Heart Journal
Print ISSN 0195-668X
Electronic ISSN 1522-9645
Publisher Oxford University Press
Peer Reviewed Peer Reviewed
Volume 36
Issue 21
Pages 1328-1334
Keywords Aneurysm, Aorta, Imaging, Rupture, Surgery, Stent grafts
Public URL
Publisher URL
Additional Information This is a copy of an open access article published in European Heart Journal, 2015, v.36 issue 21. IMPROVE trial Principal Investigators (in order of site start date from earliest to most recent); numbers in parentheses indicate the number of patients entered into the trial: United Kingdom: Nicholas J. Cheshire, Imperial College Healthcare NHS Trust, London (20); Jonathan R. Boyle, Addenbrooke's Hospital, Cambridge (40); Ferdinand Serracino-Inglott (J. Vince Smyth Dec 2012–Nov 2013), Manchester Royal Infirmary, Manchester (69); Matt M. Thompson, Robert J. Hinchliffe, St. George's Hospital, London (75); Rachel Bell, Guy's and St. Thomas' Hospital, London (81); Noel Wilson, Kent and Canterbury Hospital, Canterbury (23); Matt Bown (Dec 2010–present), Martin Dennis (to Dec 2010), Leicester Royal Infirmary, Leicester (18); Meryl Davis, Royal Free Hospital, London (1); Ray Ashleigh, University Hospital of South Manchester, Manchester (21); Simon Howell, Leeds General Infirmary, Leeds (23); Michael G. Wyatt, Freeman Hospital, Newcastle (23); Domenico Valenti, King's College Hospital, London (2); Paul Bachoo, Aberdeen Royal Infirmary, Aberdeen (4); Paul Walker, James Cook University Hospital, Middlesborough (5); Shane MacSweeney, Queen's Medical Centre, Nottingham (34); Jonathan N. Davies, Royal Cornwall Hospital, Truro (5); Dynesh Rittoo (Jan. 2012–present), Simon D. Parvin (to Dec. 2011), Royal Bournemouth Hospital, Bournemouth (22); Waquar Yusuf, Royal Sussex County Hospital, Brighton (5); Colin Nice, Queen Elizabeth Hospital, Gateshead (5); Ian Chetter, Hull Royal Infirmary, Hull (32); Adam Howard, Colchester General Hospital, Colchester (24); Patrick Chong, Frimley Park Hospital, Surrey (14); Raj Bhat, Ninewells Hospital, Dundee (8); David McLain, Royal Gwent Hospital, Newport; Andrew Gordon (Jun. 2012–present), Ian Lane (to Jun. 2012), University Hospital of Wales, Cardiff (4); Simon Hobbs, New Cross Hospital, Wolverhampton (3); Woolagasen Pillay, Doncaster Royal Infirmary, Doncaster (8); Timothy Rowlands (Nov. 2012–present), Amin El-Tahir (to Nov. 2012), Royal Derby Hospital, Derby (13); John Asquith, University Hospital of North Staffordshire, Stoke-on-Trent (15); Steve Cavanagh, York Hospital, York (3); Canada: Thomas L. Forbes, London Health Sciences Centre, The University of Western Ontario, London, ON (13). Trial Coordinators: Ayoola Awopetu, Sara Baker, Patricia Bourke, Claire Brady, Joanne Brown, Jennie Bryce, Christine Bufton, Tina Chance, Angela Chrisopoulou, Marie Cockell, Andrea Croucher, Gail Curran, Leela Dabee, Nikki Dewhirst, Jo Evans, Andy Gibson, Siobhan Gorst, Moira Gough, Lynne Graves, Michelle Griffin, Josie Hatfield, Florence Hogg, Susannah Howard, Thomas Hughes, Alex James, David Metcalfe, Michelle Lapworth, , Ian Massey, Awad Mohalhal, Teresa Novick, Gareth Owen, Noala Parr, David Pintar, Tom Smith, Sarah Spencer, Claire Thomson, Orla Thunder, Tom Wallace, Sue Ward, Vera Wealleans, Lesley Wilson, Janet Woods, Manu Zachariah, Ting Zheng.


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Copyright Statement
&The Author 2015. Published by Oxford University Press on behalf of the European Society of Cardiology.This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (, whichpermits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contactjournals.permissions@oup.comEuropean Heart Journaldoi:10.1093/eurheartj/ehu521European Heart Journal Advance Access published January 27, 2015by guest on January 28, 2015Downloaded from

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