• IMPROVE Trial Investigators, Janet T Powell, Michael J Sweeting, Matthew M Thompson, Ray Ashleigh, Rachel Bell, Manuel Gomes, Roger M Greenhalgh, Richard Grieve, Francine Heatley, Robert J Hinchliffe, Simon G Thompson, and Pinar Ulug.
• BMJ. 2014 Jan 1;348:f7661.

ObjectiveTo assess whether a strategy of endovascular repair (if aortic morphology is suitable, open repair if not) versus open repair reduces early mortality for patients with suspected ruptured abdominal aortic aneurysm.DesignRandomised controlled trial.Setting30 vascular centres (29 UK, 1 Canadian), 2009-13.Participants613 eligible patients (480 men) with a clinical diagnosis of ruptured aneurysm.Interventions316 patients were randomised to the endovascular strategy (275 confirmed ruptures, 174 anatomically suitable for endovascular repair) and 297 to open repair (261 confirmed ruptures).Main Outcome Measures30 day mortality, with 24 hour and in-hospital mortality, costs, and time and place of discharge as secondary outcomes.Results30 day mortality was 35.4% (112/316) in the endovascular strategy group and 37.4% (111/297) in the open repair group: odds ratio 0.92 (95% confidence interval 0.66 to 1.28; P=0.62); odds ratio after adjustment for age, sex, and Hardman index 0.94 (0.67 to 1.33). Women may benefit more than men (interaction test P=0.02) from the endovascular strategy: odds ratio 0.44 (0.22 to 0.91) versus 1.18 (0.80 to 1.75). 30 day mortality for patients with confirmed rupture was 36.4% (100/275) in the endovascular strategy group and 40.6% (106/261) in the open repair group (P=0.31). More patients in the endovascular strategy than in the open repair group were discharged directly to home (189/201 (94%) v 141/183 (77%); P<0.001). Average 30 day costs were similar between the randomised groups, with an incremental cost saving for the endovascular strategy versus open repair of £1186 (€1420; $1939) (95% confidence interval -£625 to £2997).ConclusionsA strategy of endovascular repair was not associated with significant reduction in either 30 day mortality or cost. Longer term cost effectiveness evaluations are needed to assess the full effects of the endovascular strategy in both men and women.Trial RegistrationCurrent Controlled Trials ISRCTN48334791.

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