Ann Vasc Surg. 2026 Mar 9:S0890-5096(26)00126-3. doi: 10.1016/j.avsg.2026.02.032. Online ahead of print.
ABSTRACT
OBJECTIVES: Elective repair for an abdominal aortic aneurysm (AAA) is performed to prevent rupture and subsequent death. The risk of early mortality is higher after open repair than after endovascular repair and needs to be reduced. Registries lack granular individual data to investigate this increased mortality. An independent, detailed, patient level analysis of the international randomised controlled ACTION-1 trial was performed to investigate the relation between thrombo-embolic, hemorrhagic or other events with mortality after open AAA repair, thereby exploring the cascade of pathological events leading to death.
METHODS: An adjudication committee was installed to assess the following domains: attributability of thrombo-embolic or bleeding event, whether the event occurred intra- or postoperative, cascade of pathological events, and cause of death. An intraoperative bleeding score was calculated to stratify the severity of bleeding.
RESULTS: In 16 out of 20 deceased patients (80%), death was attributable to a thrombo-embolic or bleeding event. Four patients (20%) succumbed to causes unrelated to a thrombo-embolic or bleeding event. Intraoperative bleeding was the primary cause of death in four patients, all of whom underwent activated clotting time-guided heparinisation. In contrast, an intraoperative thrombo-embolic event was the primary cause of death in one patient who had received 5 000 IU of heparin.
CONCLUSION: In a randomised controlled trial on 297 patients with open AAA repair, 16 out of 20 (80%) deaths were due to bleeding or thrombo-embolic events. In most deceased patients, increased perioperative bleeding resulted in a pathological cascade of hypoperfusion, organ failure and shock. Bleeding- and thrombo-embolic complications must be addressed to reduce mortality after elective open AAA repair.
PMID:41812887 | DOI:10.1016/j.avsg.2026.02.032