Ruptured abdominal aortic aneurysm in the Huntingdon district: a 10-year experience.

A study was undertaken to establish the true incidence of ruptured abdominal aortic aneurysms (RAAA) in the Huntingdon districts. RAAAs in the Huntingdon district between 1986 and 1995 were studied retrospectively. Data were collected from hospital records and hospital and community autopsies. There was a total of 139 cases of RAAA; 119 were males and 20 females, giving a M:F ratio of 6:1. The incidence of RAAAs was 17.8/100,000 person years (py) in males and 3.0/100,000 py in females. Mean age at rupture was 75.5 years in men (95% confidence intervals (CI) 74-78 years) and 80.2 in women (95% CI 78.8-83 years). There was an age-specific increase in incidence after the age of 65 years in men and after 80 years in women, although 12.6% of all RAAAs occurred in men under 65 years. In all, 100 patients were confirmed to have died of RAAA during the 10-year period. This represents 79% of all ruptures discovered. Almost three-quarters of patients did not reach the operating theatre. Of the 61 patients operated on, 29 survived (48%). The size of the aneurysm at rupture was recorded in 68 cases (49%). The mean size was 8.14 cm (SD 2.0 cm). In five cases (7.4%), rupture occurred in AAAs smaller than 6 cm. The overall mortality from RAAA in Huntingdon health district is approximately 80% and three-quarters of all deaths occurred without an operation.     

Abdominal aortic aneurysm surgery in a district general hospital: a 15-years experience

The incidence of patients presenting with both ruptured abdominal aortic aneurysm (RAAA) and elective abdominal aortic aneurysm (EAAA) increases with age. The aim of our study was to find out the incidence of RAAA, age and sex groups of patients at risk, and 30-day all-cause perioperative mortality associated with RAAA as well as EAAA repair in a busy district general hospital over a 15-year time period. All patients operated for AAA during 1989-2003, both elective and ruptured, were included in the study. Patients who died in the community from RAAA were also included. The data were collected from the hospital information system, theater logbooks, intensive therapy unit records, postmortem register, and patients' medical notes. We divided the data for RAAA into two groups of 7.5 years each to see if there was any improvement over time in 30-day postoperative mortality. There were 816 cases of AAA, which included 468 RAAAs (57%) and 348 EAAAs (43%). Out of 468 RAAAs, 243 patients had emergency repair, of whom 213 were males. There were 201 patients who had RAAA postmortem (43%). Median age (range) was 73 (54-94) years in males and 77 (52-99) years in females, with a male-to-female ratio of 7:1. The peak incidence of RAAA was over 60 years of age in males and 70 years in females. Incidence of RAAA was 7.3/100,000/year in males and 5/100,000/year in females. For RAAA, 30-day perioperative mortality was 43% (105/243) while overall mortality was 70% (330/468), which includes deaths in the community. There was no improvement in 30-day mortality over time after comparing data for the first 7.5 years (50/115, 43.5%) with those for the second set of 7.5 years (55/128, 43%). There were 348 patients who had EAAA repair over the same period, comprising 282 males, with a male:female ratio of 4.3:1. The 30-day mortality in the elective group was 7.75%. Incidence and mortality of RAAA remain high. A high proportion of patients with AAA remain undiagnosed and die in the community. More lives may be saved if a screening program is started for AAA.     

A statewide, population-based time-series analysis of the outcome of ruptured abdominal aortic aneurysm.

OBJECTIVES: The purpose of this study was to perform the first statewide, population-based, time-series analysis of the frequency of ruptured abdominal aortic aneurysm (RAAA), to determine the outcomes of RAAA, and to assess the association of patient, physician, and hospital factors with survival after RAAA. The hypotheses of the study were as follows: 1) the rate of RAAA would increase over time and 2) patient, surgeon, and hospital factors would be associated with survival. BACKGROUND: Ruptured abdominal aortic aneurysm is a life-threatening emergency that presents the surgeon with a technically demanding challenge that must be met and surmounted in a short time if the patient is to survive. METHODS: Data were obtained from the following four separate data sources: 1) the North Carolina Hospital Discharge database, 2) the North Carolina American Hospital Association database, 3) the North Carolina State Medical Examiner's database, and 4) the Area Resource File. All patients with the diagnosis of an abdominal aortic aneurysm (AAA) were selected for initial assessment. Patients were grouped into those with and those without rupture of the abdominal aneurysm. RESULTS: During the 6 years of the study, 14,138 patients were admitted with a diagnosis of AAA. Of these, 1480 (10%) had an RAAA. The yearly number of patients with elective AAAs increased 33% from 1889 in 1988 to 2518 in 1993. The yearly number of RAAAs increased 27% from 203 to 258. The mortality rate for AAA was 5%, as compared with 54% in RAAA patients. The patient's age was found to be the most powerful predictor of survival. Univariate logistic regression analyses demonstrated an association of the surgeon's experience with RAAA and patient survival after RAAA. Analysis of the survival rates of board-certified and nonboard-certified surgeons demonstrated that patients with RAAAs who were treated by board-certified surgeons had significantly better survival. When the survival was compared in small (less than 100 beds) and large (more than 100 beds) hospitals, survival was significantly better in the larger hospitals. CONCLUSIONS: Ruptured abdominal aortic aneurysm remains a highly lethal lesion, even in the best of hands. Despite the many improvements in the care of seriously ill patients, there was no significant improvement in the survival of RAAA during this study. This suggests that early diagnosis is the best hope of survival in these patients. The study demonstrated that survival after RAAA was related most strongly to patient age at the time of the RAAA. The physician's and the hospital's experience with RAAA, the physician's background as measured by board certification, and the type of hospital at which the operation was performed (small vs. large) also may be associated with survival. These findings may have important implications for the regionalization of care and the education and credentialling of physicians. Given the lack of recent progress of improving the outcome of RAAA, aggressive efforts to treat patients before rupture are appropriate.     

The true incidence of ruptured abdominal aortic aneurysms

The number of ruptured abdominal aortic aneurysms (RAAA) was documented over an 8-year-period in a known population age group. Patient figures were collected from the operative and post-mortem registers in the Worthing Health District. The overall mean incidence of RAAA was 13.9/100,000 patient years, although the incidence was noted to increase from 9.2 to 17.5/100,000 patient years during this period. The incidence in the male population rose from 4.7/100,000 for those in the fifth decade to 184.8/100,000 for those above 80. For patients undergoing operation, the peri-operative survival was 38%, however the overall survival was 11% as 64% of patients died at home. These figures demonstrate an increasing incidence of ruptured AAA. They also add support to the need for screening of asymptomatic abdominal aortic aneurysms and elective repair if the incidence and hence mortality is to be reduced.     

Projected workload for a vascular service in 2020.

OBJECTIVE: to estimate the workload of a vascular service during the next two decades as the proportion of people aged over 65 years increases. METHODS: the study used the vascular registry data of Tampere University Hospital and the population data of Pirkanmaa region provided by the Central Statistical Office in Finland. The current workload is 1420 vascular procedures per million inhabitants yearly (951 surgical and 207 endovascular). Sixty-five per cent of all procedures are done on people over 65 years old. Pirkanmaa has a population of 440 000 persons of whom 15.6% are over 65 years. According to the population data the population will increase to 460 000 persons by the year 2020 and 22.9% of them will be over 65 years old. RESULTS: The total amount of procedures will rise by 40.5% (1906) and the increase in endovascular and surgical group will be 39.2% (640) and 43.5% (1265) respectively. The proportion of treated patients over 65 years will rise from 65.0% to 70.5%. In the next two decades the amount of patients with claudication will increase by 35.4%, critical limb ischaemia by 44.2%, carotid surgery by 34.0%, abdominal aortic aneurysms by 40.7%, acute limb ischaemia by 45.0% and access surgery by 27.4%. CONCLUSION: In the next two decades the number of elderly people will increase so rapidly that, whatever happens to the incidence and prevalence of peripheral vascular disease, the workload for a vascular service will increase significantly.     

Clamp before you cut: Proximal control of ruptured abdominal aortic aneurysms using endovascular balloon occlusion--Case reports

While the mortality rate for elective abdominal aortic aneurysm (AAA) repair has declined over the last several decades, the rate for ruptured abdominal aortic aneurysm (RAAA) has unfortunately remained disturbingly high. Undiagnosed aneurysms may present with little warning until abdominal pain, syncope, and hypotension signify rupture. Fifty percent of patients with ruptured aneurysms die before reaching a medical facility, and their survival is highly dependent on hemodynamic stability at presentation. The degree of rupture containment and comorbid status of the patient determine hemodynamic stability. Endovascular stent grafting has significantly improved perioperative morbidity and mortality rates for elective AAA repair, and some of the same endovascular techniques can be used to obtain proximal control in patients presenting with RAAA. We describe 3 consecutive cases of RAAA where proximal control was obtained using a percutaneously placed, transfemoral aortic occlusion balloon before induction of anesthesia.     

Rupture of abdominal aortic aneurysm (RAAA)--predictors of the early postoperative mortality

PURPOSE: To evaluate the main factors of the 30 days mortality rate of patients operated on for abdominal aortic aneurysm rupture (RAAA. PATIENTS AND METHOD: Univariate and multivariate analysis of various factors associated with RAAA was performed in a group of 73 patients operated on for RAAA between 1996-2001. RESULTS: The 30 days mortality rate was 35.6 %. The main factors of mortality were: misdiagnosis, cardio- pulmonary-cerebral resuscitation (CPCR) on admission, configuration of RAAA, number of blood transfusions, hypotension on admission (p < 0.0001) and duration of operation, type of reconstruction and hypertension in anamnesis (p < 0.01). Important factors (p < 0.05) of postoperative mortality were also low haemoglobin level on admission, abdominal aortic aneurysm (AAA) diameter and ischaemic heart disease in anamnesis. The probability of patient's death is the highest (p < 0.003), if factors like CPCR, number of blood transfusions and aneurysm diameter are combined (multivariate analysis, stepwise method). CONCLUSION: The early detection and surgical or endovascular elective treatment of AAA, the regular dispensation of patients with small AAA especially in hypertonics, the correct diagnosis of RAAA without time delay are the best tools for patients survival. The patient's chance for survival increases with highly trained prehospital resuscitation system and experienced team of vascular surgeons and anesthesiologists.     

Is there a selection bias in applying endovascular aneurysm repair for rupture?

Accumulating data suggest that endovascular repair (EVAR) of ruptured abdominal aortic aneurysms (RAAAs) leads to reduced mortality, but concern exists that this may reflect selection bias. We reviewed our overall rupture experience early after our protocol was instituted to explore this question. We instituted a defined protocol for RAAA with emphasis on EVAR in July 2002, which included device availability (consignment), preoperative training, 24-hr access to our surgical endosuite and ability to operate imaging in an emergency, and immediate availability of a transbrachial balloon cutdown cart for all cases. Charts of all RAAA patients who arrived in the operating room alive since institution of our protocol were reviewed. Computed tomographic (CT) scans were re-reviewed to assess potentially suitable anatomic candidates. From July 2002 to May 2006, a total of 52 RAAAs were treated at our institution: 15 pararenal RAAAs, all treated by open repair (PR-OPEN), and 37 infrarenal RAAAs, 20 treated by open repair (IR-OPEN) and 17 treated by EVAR (IR-EVAR, 32% of all ruptures). Mortality rates in the three groups were 47%, 75%, and 35% (p < 0.02 vs. IR-OPEN), respectively. Although mortality was significantly lower in the EVAR group, overall mortality was 53% (28/52). On re-review of the operative notes and CT scans, it is estimated that more than half of those cases repaired using open techniques could have been repaired using EVAR based on anatomic criteria alone. The most common reason for open repair was hemodynamic instability preoperatively; only a minority of cases were excluded from EVAR based on unfavorable anatomy after CT scan review in the emergency room. In conclusion, during our early experience EVAR for rupture was associated with significantly reduced mortality. However, our overall mortality was no different from historical values, and this fact along with the extremely high mortality seen in the IR-OPEN group suggest that we are simply selecting patients with the greatest chance of survival to undergo EVAR. It also appears that many patients who are anatomically suitable for EVAR are undergoing open operation because of hemodynamic instability. If EVAR for rupture truly decreases mortality in all patients, a much more aggressive attitude toward EVAR may be required to lower the overall mortality rate.     

Mortality in ruptured abdominal aortic aneurysms. The Finnvasc Study Group.

OBJECTIVE: To assess mortality related to rupture of abdominal aortic aneurysm (RAAA). DESIGN: A 4-year cross-sectional study based on a nationwide vascular registry Finnvasc and national cause-of-death registry (Statistics Finland). MATERIALS AND METHODS: A total of 454 operations for RAAA among 11,747 surgical vascular reconstructions recorded in the Finnvasc registry and 1004 deaths due to RAAA during the same period based on Statistics Finland. RESULTS: The operative mortality rate was 49% based on the Finnvasc registry and 54% based on Statistics Finland. With all RAAA deaths at hospitals included, total hospital mortality was 68%. No association existed between hospital volume of RAAA operations and surgical mortality, although an inverse association did exist between hospital volume of RAAA operations and all RAAA deaths in the hospital (p = 0.01). The case fatality for RAAA in Finland was 80%. CONCLUSIONS: RAAA surgical mortality calculations for RAAA, based on a vascular registry, underestimate the true rate because some cases with fatal outcome tend to escape registration. Because surgical mortality rates may also be skewed by patient selection, total hospital RAAA mortality thus represents the results of RAAA treatment more accurately.     

Ruptured abdominal aortic aneurysm, a "two-hit" ischemia/reperfusion injury: evidence from an analysis of oxidative products.

PURPOSE: Ruptured abdominal aortic aneurysm (RAAA) remains a lethal condition despite improvements in perioperative care. The consequences of RAAA are hypothesized to result from a combination of two ischemia/reperfusion events: hemorrhagic shock and lower torso ischemia. Ischemia/reperfusion results in tissue injury by diverse mechanisms, which include oxygen free radical-mediated injury produced from activated neutrophils, xanthine oxidase, and mitochondria. Oxygen-free radicals attack membrane lipids, resulting in membrane and subsequently cellular dysfunction that contributes to postoperative organ injury/failure. The purpose of this investigation was to quantify the oxidative injury that occurs as a result of the ischemia/reperfusion events in RAAAs and elective AAAs. METHODS: Blood samples were taken from 22 patients for elective AAA repair and from 14 patients for RAAA repair during the perioperative period. Plasma F(2)-isoprostanes were extracted, purified, and measured with an enzyme immunoassay. Aldehydes and acyloins were purified and quantified. Neutrophil oxidative burst was measured in response to a receptor independent stimulus (phorbol 12-myristate 13-acetate) with luminol-based chemiluminescence. RESULTS: Plasma from patients with RAAAs showed significantly elevated F(2)-isoprostane levels on arrival at hospital and were significantly elevated as compared with the levels of patients for elective repair throughout the perioperative period (two-way analysis of variance, P <.0001). Multiple regression showed a significant relationship between the phagocyte oxidative activity and F(2)-isoprostane levels (P <.013). Total acyloin levels were significantly higher in patients with RAAAs as compared with the levels in elective cases. CONCLUSION: The F(2)-isoprostane levels, specific markers of lipid peroxidation, showed that patients with RAAAs had two phases of oxidative injury: before arrival at hospital and after surgery. The significant relationship between the postoperative increases in F(2)-isoprostane levels and the neutrophil oxidant production implicates neutrophils in the oxidative injury that occurs after RAAA. New therapeutic interventions that attenuate neutrophil-mediated oxidant injury during reperfusion may decrease organ failure and ultimately mortality in patients with RAAAs.     

The influence of screening on the incidence of ruptured abdominal aortic aneurysms.

PURPOSE: The purpose of this study was to estimate the influence of a screening program on the incidence and mortality of ruptured abdominal aortic aneurysms (RAAAs). METHODS: The effects of screening on the incidence and death rate of RAAAs were investigated with a stepped wedge study design. RAAAs that occurred in the Huntingdon district were traced with an examination of all hospital records and community postmortem records. RESULTS: During the 5-year period from 1991 to 1996, 78 RAAAs occurred in the Huntingdon district: 62 in men and 16 in women. Eleven of the 62 men with RAAAs had been invited for screening. The incidence of RAAA in the invited group was 3.7 per 10,000 person-years (py; 95% confidence interval [CI], 1.5 - 7.3). In the noninvited group, the incidence was 7.3 per 10,000 py (95% CI, 5.3. - 9.2), a rate ratio of 0.51 (95% CI, 0.26 - 0.97). The mortality of rAAAs in the invited group was 3.0 per 10, 000 py (95% CI, 1.4 - 5.4) as compared with 5.4 per 10,000 py in the noninvited group (95% CI, 3.9 - 7.3), resulting in a rate ratio of 0. 55 (95% CI, 0.26 - 1.15). CONCLUSION: Screening for asymptomatic AAAs can reduce the incidence rate of RAAAs by 49% (95% CI, 3% - 74%).     

Endovascular repair of ruptured abdominal aortic aneurysms: systematic literature review

Endovascular repair is increasingly used for ruptured abdominal aortic aneurysms (RAAAs). This study estimated the mortality rate for this approach. A review of 307 publications in English was performed. Thirty-four publications representing 1,200 patients with RAAA were deemed appropriate for analysis by weighted least squares regression. Of the 1,200 patients, 531 (44.3%) underwent endovascular aneurysm repair (EVAR). The average age was 74 years, and 13% were female. Aortouni-iliac grafts were used in 49.4% of patients, and 50.6% received bifurcated grafts. The technical success rate was 94.9%, with a mortality rate of 30.2%. The ratio of endovascular cases to the total number of cases strongly predicted the mortality rate (weighted coefficient -0.378, p< .0003). The mortality rate following EVAR of RAAA is 30%. A 3.8% reduction in mortality was found for each 10% increase in the percentage of ruptures repaired endovascularly at each center. These results are suggestive of a learning curve.     

Ruptured versus Elective Abdominal Aortic Aneurysm Repair: Outcome and Cost

During a recent 30-month period, we repaired 10 ruptured abdominal aortic aneurysms (RAAA) at our institution. To evaluate the survival, postoperative morbidity, and financial impact of treating RAAA, we compared these patients with 10 randomly selected patients undergoing elective AAA (EAAA). Both groups were comparable for age, gender, and incidence of diabetes, hypertension, coronary artery disease, chronic obstructive pulmonary disease (COPD), and renal failure. Although we have noted a dramatic increase in survival for RAAA (90%), the morbidity continues to be unacceptably high (60%). Efforts should be made toward better detection of AAA prior to rupture as well as development of strategies to minimize or prevent these major complications. Potential average savings accrued from one patient undergoing EAAA repair rather than RAAA repair ($93,139. 21) can be used to perform screening abdominal ultrasound tests in patients at increased risk of having an AAA.     

Improved outcome after rupture of abdominal aortic aneurysm over an 18-year period

The purpose of the study was to analyze changes in in-hospital mortality of patients with ruptured abdominal aortic aneurysm (RAAA) during an 18-year period. A retrospective analysis of 246 patients with RAAA in the years 1987-2005 was performed. The patients were divided into groups that consisted of 111 patients treated in the years 1987-2000 (group I) and 135 patients treated in the years 2001-2005 (group II). The in-hospital mortality rates of all patients and of operated patients in both groups were analyzed. Preoperative variables such as age, gender, size of the aneurysm, duration of symptoms, distance to the vascular surgery department, full blood count, serum creatinine and urea concentrations, and systolic and diastolic blood pressures, as well as the number of all AAAs and RAAAs treated per year, were compared between the groups. The Mann-Whitney U-test and Fisher exact test were used to analyze differences in continuous and categorical variables, respectively. The in-hospital mortality of all patients was significantly lower in group II (p = 0.006) The difference in in-hospital mortality of operated patients was of borderline statistical significance (p = 0.07). The proportion of nonoperated patients decreased from 21% to 6% (p = 0.0008). The patients from group II had significantly higher preoperative levels of hemoglobin, hematocrit, erythrocytes, and platelets, as well as higher systolic and diastolic blood pressure and smaller diameter of aneurysm. The number of both all aneurysms and RAAAs per year was significantly higher in group II. The improved preoperative status of the patients and more aggressive surgical approach are associated with reduction in in-hospital mortality of patients with RAAA. The increased experience of the center may also improve outcome of RAAA.     

A comparison between the short term and long term benefits of screening for abdominal aortic aneurysms from the Huntingdon Aneurysm screening programme.

BACKGROUND: The UK Multicentre Aneurysm Screening Study (MASS) showed a 44% reduction in AAA-related mortality after 4 years and predicted an increased number of deaths prevented in the longer term. We aim to compare the 5 and 13 years benefit from aneurysm screening in the Huntingdon Aneurysm screening programme. METHODS: Incidence and mortality of ruptured AAA (RAAA) after 5 and 13 years of screening in a population based aneurysm screening program. RESULTS: Five years of screening resulted in a reduction in the incidence of RAAA of 49% (95% CI: 3-74%). Nine out of 11 ruptures in the invited group did not survive (mortality 82%; 95% CI: 48-98%) compared to 38 non-survivors from 51 ruptures in the control group (mortality 75%; 95% CI: 60-86%). Five years of screening resulted in an RAAA-related mortality reduction of 45% (95% CI: -15 to 74%). After 13 years of screening the incidence of RAAA was reduced by 73% (95% CI: 58-82%). Twenty-one out of 29 ruptures in the invited group did not survive (mortality 72%; 95% CI: 53-87%) compared to 64 non-survivors from 82 ruptures in the control group (mortality 78%; 95% CI: 68-86%). Thirteen years screening resulted in a reduction of mortality from RAAA of 75% (95% CI: 58-84%). The number needed to screen to prevent one death reduced from 1380 after 5 years to 505 after 13 years. The number of elective AAA operations needed to prevent one death reduced from 6 after 5 years to 4 after 13 years. CONCLUSION: AAA screening becomes increasingly beneficial as screening continues over the longer term. Benefits continue to increase after screening has ceased.     

Endovascular approaches to ruptured infrarenal aorto-iliac aneurysms

BACKGROUND: Ruptured abdominal aortoiliac aneurysms (RAAAs) carry a high mortality when treated by open surgical repair. Since 1994, we have employed endovascular approaches to treat this entity. METHODS: Patients with presumed RAAAs were treated with restricted fluid resuscitation (hypotensive hemostasis), rapid transport to the operating room, placement of a transbrachial or transfemoral guidewire under local anesthesia, and urgent arteriography. In patients with suitable anatomy, endovascular graft repair was performed. If the anatomy was unsuitable, standard open repair was performed. If the patient had circulatory collapse, proximal balloon control was employed. RESULTS: Of 31 patients managed in this fashion, 25 underwent endovascular graft repair. Six required open repair. Total operative mortality was 9.7% (3 patients). Only 10 patients required proximal balloon aortic control. CONCLUSIONS: Endovascular techniques (proximal balloon control and endografts) may improve treatment outcomes for RAAAs. Restricted resuscitation (hypotensive hemostasis) can be effective in the RAAA setting.     

Epidemiology and Outcome of Aortic Aneurysms in Hong Kong

Abstract The objective of this study was to determine epidemiology and mortality statistics for abdominal aortic aneurysms (AAAs) in Hong Kong. Data from three sources were obtained and analyzed: (1) Hong Kong Hospital Authority discharge statistics for 1999 and 2000; (2) a survey on aortic aneurysms in public hospitals conducted by the Working Group of Vascular Surgery; and (3) the Department of Surgery, University of Hong Kong Medical Center aortic aneurysm database. The disease pattern, distribution, and operative mortality were determined. The annual incidence of AAA in Hong Kong is 13.7 per 100,000 population and 105 per 100,000 for those aged 65 and above. About 10% of the AAAs that presented were ruptured. The mean age of the AAA patients was 74 years, with 84% of them over age 65. The operative repair rate for AAAs was low, being only 8% for intact aneurysms and 54% for ruptured ones. Overall, 45% of all aneurysm repairs were performed for a ruptured AAA. There is diverse practice between major vascular centers and smaller regional hospitals. The territory-wide operative mortality rates for intact and ruptured aneurysms were 10% (range 4–24%) and 70% (range 38––100%), respectively. There was no gender bias in the rupture and operative rates. The overall mortality was 17% for intact AAAs and 78% for ruptured AAAs. The average length of hospital stay was 19 days for elective AAA surgery and 13 days for ruptured AAAs. The number of operations in high-volume centers is increasing with a concomitant decrease in operative mortality. There are no definitive data to indicate that the incidence of AAAs is rising, but a trend toward an increasing number of operations in referral centers is noted. The low repair rates for intact AAAs and the high proportion of repairs for ruptured aneurysms suggest that AAAs are undertreated in Hong Kong.     

Increasing incidence of ruptured abdominal aortic aneurysm: a population-based study

OBJECTIVE: The aim of the present population-based study was to assess the trends of age- and gender-specific incidence of ruptured abdominal aortic aneurysm (rAAA). METHODS: Patients with rAAA from the city of Malm?, Sweden, were studied between 2000 and 2004. An analysis of trends of incidence and mortality of rAAA in Malm? was possible because of a previous population-based study on patients with rAAA between 1971 and 1986 (autopsy rate 85% compared with 25% for the time period 2000 to 2004). The in-hospital registry of Malm? University Hospital and the databases at the Department of Pathology, Malm?, and the Institution of Forensic Medicine, Lund, identified patients with rAAA, and the in-hospital registry identified all elective repairs for AAA. RESULTS: Compared with the time period 1971 to 1986, the overall incidence of rAAA significantly increased from 5.6 (95 % confidence interval [CI], 4.9 to 6.3) to 10.6 (95% CI, 8.9 to 12.4) per 100,000 person-years (standardized mortality ratio, 1.6; 95% CI, 1.0 to 2.1). In men aged 60 to 69 and 70 to 79 years, the incidence increased significantly from 16 (95% CI, 11 to 21) and 56 (95% CI, 43 to 69) to 46 (95% CI, 28 to 63) and 117 (95% CI, 84 to 149) per 100,000 person-years, respectively, whereas no increase in the age-specific incidence in women could be demonstrated. The overall incidence of elective repair of AAA increased significantly from 3.4 (95% CI, 2.8 to 4.0) to 7.0 (95% CI, 5.6 to 8.4) per 100,000 person-years and increased most significantly from 12 (95% CI, 3.4 to 32) to 68 (95% CI, 34 to 102) per 100,000 person-years in men aged 80 to 89 years and from 5.1 (95% CI, 2.4 to 9.3) to 28 (95% CI, 15 to 41) per 100,000 person-years in women aged 70 to 79 years. The elective-acute repair ratio in women increased from 2.4 to 5.6 and decreased in men from 2.1 to 1.0. CONCLUSIONS: Between 1971 to 1986 and 2000 to 2004, the incidence of rAAA increased significantly, despite a 100% increase in elective repairs and notwithstanding a potential for bias towards underestimation due to lower autopsy rates in recent years. The reason behind this increase is unclear, and further studies are needed to identify risk groups for direction of effective prevention and screening.     

Contemporary results of open repair of ruptured abdominal aortoiliac aneurysms: effect of surgeon volume on mortality

OBJECTIVE: The purpose of this study is to evaluate contemporary results of ruptured aortoiliac aneurysms (RAAA) and identify the role of surgeons' annual aortic volume and other prognostic indicators for early outcome. METHODS: A retrospective review identified 213 consecutive patients who presented with an atherosclerotic RAAA without thoracic extension over 6.5 years ending in June 2007. Excluded were 31 ruptures treated by endovascular repair (EVAR) or following previous EVAR, also excluded were two chronic asymptomatic hemodynamically stable ruptures. Ten patients were not treated due to either patient's refusal or prohibitive surgical risk. Demographic, preoperative, intraoperative, and postoperative variables were collected. Log rank test and Cox proportional hazard model analyses were utilized to identify factors contributing to mortality and morbidity in these patients. Survival rates were estimated by Kaplan-Meier method. RESULTS: One hundred thirty-one males and 39 females with a mean age of 74.5 +/- 8.1 years underwent consecutive RAAA repairs. The operative mortality rate was 38.2% (65/170), including 29 intraoperative deaths. Using multivariate analysis, surgeon's average annual AAA volume (<20/y), advanced age, and postoperative intestinal ischemia were independent predictors of perioperative deaths. Shock on presentation, preoperative cardiopulmonary resuscitation or free rupture were not. High-volume surgeons (>20 average annual AAA cases/y) had a higher 30-day survival rates (78.4% vs 57.9%, P = .024). Octogenarians had a lower 30-day survival rate of 49.0% vs 70.5% (P = .012). Patients who developed postoperative intestinal ischemia had a lower 30-day survival rate compared with patients without (48.1% vs 15.3%, P = .002). Increased intraoperative fluid and blood product usage was associated with bowel ischemia (P < .05). CONCLUSIONS: RAAA remains a highly lethal problem. The improved early outcomes of surgeons with high-volume AAA have strong implications for training, emergency staffing needs and alternative treatment strategies.     

Outcomes of endovascular treatment of ruptured abdominal aortic aneurysms

INTRODUCTION: The successful application of endovascular techniques for the elective repair of abdominal aortic aneurysms (AAAs) has stimulated a strong interest in their possible use in dealing with a long-standing surgical challenge: the ruptured abdominal aortic aneurysm (RAAA). The use of a conventional open procedure to repair ruptured aneurysms is associated with a high operative mortality of 45% to 50%. In this study, we evaluated the current frequency of endovascular repair of RAAAs in four large states and the impact of this technique on patient outcome. METHODS: We examined discharge data sets from 2000 through 2003 from the four states of California, Florida, New Jersey, and New York, whose combined population represents almost a third of the United States population. Proportions and trends were analyzed by chi2 analysis and continuous variables by the Student's t test. RESULTS: We found that since the year 2000, endovascular repair has begun to emerge as a viable treatment option for RAAAs, accounting for the repair of 6.2% of cases in 2003. During the same period, the use of open procedures for RAAAs declined. The overall mortality rate for the 4-year period was significantly lower for endovascular vs open repair (39.3% vs. 47.7%, P = .005). Moreover, compared with open repair, endovascular repair resulted in a significantly lower rate of pulmonary, renal, and bleeding complications. Survival after endovascular repair correlated with hospital experience, as assessed by the overall volume of elective and nonelective endovascular procedures. For endovascular repairs, mortality ranged from 45.9% for small volume hospitals to 26% for large volume hospitals (P = .0011). Volume was also a determinant of mortality for open repairs, albeit to a much lesser extent (51.5% for small volume hospitals, 44.3% for large volume hospitals; P < .0001). CONCLUSION: We observed a benefit to using endovascular procedures for RAAAs in institutions with significant endovascular experience; however, the analysis of administrative data cannot rule out selection bias as an explanation of better outcomes. These data strongly endorse the need for prospective studies to clarify to what extent the improved survival in RAAA patients is to be attributed to the endovascular approach rather than the selection of low-risk patients.