Value of the Glasgow Aneurysm Score in predicting the immediate and long-term outcome after elective open repair of infrarenal abdominal aortic aneurysm

BACKGROUND: This study aimed to explore the value of the Glasgow Aneurysm Score in predicting the immediate and long-term outcome after elective open repair of abdominal aortic aneurysm (AAA). METHODS: Some 403 patients underwent elective open repair of an infrarenal AAA and were classified retrospectively according to the criteria of the Glasgow Aneurysm Score (risk score = (age in years) + (7 for myocardial disease) + (10 for cerebrovascular disease) + (14 for renal disease)). RESULTS: Fourteen patients (3.5 per cent) died after operation, 23 (5.7 per cent) had a myocardial infarction and six (1.5 per cent) had a stroke. One hundred and nine patients (27.0 per cent) experienced severe postoperative complications. The Glasgow Aneurysm Score was predictive of postoperative death (area under the receiver-operator characteristic curve (AUC) 0.80, 95 per cent confidence interval (c.i.) 0.71 to 0.90), severe postoperative complications (AUC 0.67, 95 per cent c.i. 0.61 to 0.73), myocardial infarction (AUC 0.72, 95 per cent c.i. 0.62 to 0.82), myocardial infarction-related postoperative death (AUC 0.78, 95 per cent c.i. 0.63 to 0.94) and stroke (AUC 0.84, 95 per cent c.i. 0.74 to 0.95). Univariate analysis showed that this risk index was also predictive of long-term survival. CONCLUSION: The Glasgow Aneurysm Score is a good predictor of outcome after elective open repair of AAA. Its simplicity and accuracy make it useful for preoperative risk stratification.     

Glasgow Aneurysm Score as a predictor of immediate outcome after surgery for ruptured abdominal aortic aneurysm

BACKGROUND: The aim of the study was to assess the value of the Glasgow Aneurysm Score in predicting postoperative death after repair of a ruptured abdominal aortic aneurysm (AAA). METHODS: Between 1991 and 1999, 836 patients underwent surgery for ruptured AAA. Their operative risk at presentation was evaluated retrospectively using the Glasgow Aneurysm Score, based on data from the nationwide Finnvasc registry. RESULTS: The operative mortality rate was 47.2 per cent (395 of 836); 164 patients (19.6 per cent) had cardiac complications and 164 (19.6 per cent) required intensive care treatment for more than 5 days. Predictors of postoperative death in univariate analysis were: coronary artery disease (P = 0.005), preoperative shock (P < 0.001), age (P < 0.001), and the Glasgow Aneurysm Score (P < 0.001). In multivariate analysis the predictors were: preoperative shock (odds ratio (OR) 2.13 (95 per cent confidence interval (c.i.) 1.45 to 3.11); P < 0.001) and the Glasgow Aneurysm Score (for an increase of ten units: OR 1.81 (95 per cent c.i. 1.54 to 2.12); P < 0.001). Receiver-operator characteristic (ROC) curves showed that the best cut-off value of the Glasgow Aneurysm Score in predicting postoperative death was 84 (area under the curve 0.75 (95 per cent c.i. 0.72 to 0.78), standard error 0.17; P < 0.001). The operative mortality rate was 28.2 per cent (114 of 404) in patients with a Glasgow Aneurysm Score of 84 or less, compared with 65.0 per cent (281 of 432) in those with a score greater than 84 (P < 0.001). CONCLUSION: The Glasgow Aneurysm Score predicted postoperative death after repair of ruptured AAA in this series.     

Comparison of risk-scoring methods in predicting the immediate outcome after elective open abdominal aortic aneurysm surgery.

BACKGROUND & OBJECTIVES: The aim of this study was to apply three simple risk - scoring systems to prospectively collected data on all elective open Abdominal Aortic Aneurysm (AAA) operations in the Cambridge Academic Vascular Unit over a 6 - year period (January 1998 to January 2004), to compare their predictive values and to evaluate their validity with respect to prediction of mortality and post-operative complications. METHODS: 204 patients underwent elective open infra-renal AAA repair. Data were prospectively collected and risk assessment scores were calculated for mortality and morbidity according to the Glasgow Aneurysm Score (GAS), VBHOM (Vascular Biochemistry and Haematology Outcome Models) and Estimation of Physiologic Ability and Surgical Stress (E-PASS). RESULTS: The mortality rate was 6.3% (13/204) and 59% (121/204) experienced a post-operative complication (30-day outcome). For GAS, VBHOM and E-PASS the receiver operating characteristics (ROC) curve analysis for prediction of in-hospital mortality showed area under the curve (AUC) of 0.84 (95% confidence interval [CI], 0.76 to 0.92; p<0.0001), 0.82 (95% CI, 0.68 to 0.95; p=0.0001) and 0.92 (95% CI, 0.87 to 0.97; p<0.0001) respectively. There were also significant correlations between post-operative complications and length of hospital stay and each of the three scores, but the correlation was substantially higher in the case of E-PASS. CONCLUSIONS: All three scoring systems accurately predicted the risk of mortality and morbidity in patients undergoing elective open AAA repair. Among these, E-PASS seemed to be the most accurate predictor in this patient population.     

Glasgow aneurysm score predicts the outcome after emergency open repair of symptomatic, unruptured abdominal aortic aneurysms.

OBJECTIVE: To determine the predictor factors of in-hospital postoperative mortality in patients presenting with symptomatic but not ruptured abdominal aortic aneurysm (AAA) at our institution. PATIENTS AND METHODS: Forty-two patients who underwent urgent open repair for symptomatic, non-ruptured AAA were evaluated retrospectively. RESULTS: Five patients (11.9%) died during the in-hospital stay. History of coronary artery disease (p=0.014), cerebrovascular diseases (p=0.015), renal failure according to Glasgow Aneurysm Score (GAS) criteria (p=0.001), serum creatinine concentration (p=0.026), and the GAS (p=0.008) were predictive of postoperative death. The ROC curve analysis showed that the Glasgow Aneurysm Score had an area under the curve of 0.870 (95%C.I. 0.71-1, S.E. 0.08, p=0.008), and its best cut-off value in predicting postoperative death was 90.0 (specificity 89.2%, sensitivity 80.0%). The postoperative mortality rate of patients with a Glasgow Aneurysm Score below 90 was 2.9%, whereas it was 50% for those with a score >or=90 (p=0.003, O.R. 33.0). CONCLUSION: This study shows that the Glasgow Aneurysm Score is a good predictor of postoperative mortality and morbidity after urgent repair of symptomatic, non-ruptured AAA and can be useful in identifying those patients whose operative risk is prohibitive. Its simplicity makes it a clinically important tool, particularly, in the emergency setting. Patients having a score less than 90 can safely undergo urgent open repair. Thorough evaluation and improvement of preoperative status followed preferably by an endovascular repair is indicated for those with a score >or=90.     

Outcome after emergency repair of symptomatic, unruptured abdominal aortic aneurysm: results in 42 patients and review of the literature

OBJECTIVE: To evaluate the results of our experience in the management of patients with symptomatic, unruptured abdominal aortic aneurysm (AAA), to identify the predictors of immediate outcome and to define the worldwide postoperative mortality rate through a review of previous studies on this condition. PATIENTS AND METHODS: Forty-two patients underwent emergency repair for symptomatic, unruptured AAA. RESULTS: Four patients (9.5%) died during the in-hospital stay, three of myocardial infarction and one of multiorgan failure. Only preoperative creatinine was predictive of postoperative death (p = 0.04, OR 1.31). The Glasgow Aneurysm Score tended to be predictive of postoperative death (p = 0.06), survivors having had a median score of 76.0 (IQR, 75.5-82.1) and patients who died of 87.1 (78.9-89.9). The receiver operating characteristic (ROC) curve analysis showed that the Glasgow Aneurysm Score had an area under the curve of 0.789 (95% CI: 0.596-0.983, SE: 0.099, p = 0.06). Its best cut-off value in predicting postoperative death was 85 (specificity 86.8%, sensitivity 75.0%). The postoperative mortality rate among patients with a Glasgow Aneurysm Score <85 was 2.9%, whereas it was 37.5% among those with a score >85 (p = 0.003). A review of the results of previous studies on this condition, including also the present series, showed that 207 out of 1312 patients (15.8%) died after emergency operation for symptomatic, unruptured AAA. CONCLUSION: Emergency open repair of symptomatic, unruptured AAA is associated with a high risk of postoperative death. The results of this study suggest that a rather good postoperative survival rate can be expected in patients with a Glasgow Aneurysm Score <85. A watchful waiting policy or, alternatively, emergency endovascular repair should be advocated in patients with a higher score.     

Outcome after emergency repair of symptomatic,unruptured abdominal aortic aneurysm: Results in 42 patients and review of the literature

Objective To evaluate the results of our experience in the management of patients with symptomatic, unruptured abdominal aortic aneurysm (AAA), to identify the predictors of immediate outcome and to define the worldwide postoperative mortality rate through a review of previous studies on this condition.

Patients and methods Forty-two patients underwent emergency repair for symptomatic, unruptured AAA.

Results Four patients (9.5%) died during the in-hospital stay, three of myocardial infarction and one of multiorgan failure. Only preoperative creatinine was predictive of postoperative death (p=0.04, OR 1.31). The Glasgow Aneurysm Score tended to be predictive of postoperative death (p=0.06), survivors having had a median score of 76.0 (IQR, 75.5–82.1) and patients who died of 87.1 (78.9–89.9). The receiver operating characteristic (ROC) curve analysis showed that the Glasgow Aneurysm Score had an area under the curve of 0.789 (95% CI: 0.596–0.983, SE: 0.099, p=0.06). Its best cut-off value in predicting postoperative death was 85 (specificity 86.8%, sensitivity 75.0%). The postoperative mortality rate among patients with a Glasgow Aneurysm Score <85 was 2.9%, whereas it was 37.5% among those with a score >85 (p=0.003). A review of the results of previous studies on this condition, including also the present series, showed that 207 out of 1312 patients (15.8%) died after emergency operation for symptomatic, unruptured AAA.

Conclusion Emergency open repair of symptomatic, unruptured AAA is associated with a high risk of postoperative death. The results of this study suggest that a rather good postoperative survival rate can be expected in patients with a Glasgow Aneurysm Score <85. A watchful waiting policy or, alternatively, emergency endovascular repair should be advocated in patients with a higher score.     

Validity of the Glasgow Aneurysm Score and the Hardman Index in predicting outcome after ruptured abdominal aortic aneurysm repair

BACKGROUND: The Glasgow Aneurysm Score and the Hardman Index have been recommended as predictors of outcome after repair of ruptured abdominal aortic aneurysm (AAA). This study aimed to assess their validities. METHODS: Patients admitted to a single unit with a ruptured AAA over a 2-year interval (2000-2001) were identified from a prospectively compiled database. Hospital records of all patients undergoing attempted operative repair were reviewed. The Glasgow Aneurysm Score and the Hardman Index were calculated retrospectively and related to clinical outcome. RESULTS: One hundred patients were admitted with a ruptured AAA. Of these, 82 underwent attempted operative repair and were included in the study: 68 men and 14 women, of median age 73 (range 54-87) years. Thirty (37 per cent) patients died after the operation. The Glasgow Aneurysm Score was a poor predictor of postoperative mortality. The area under the Receiver-Operator Characteristic curve was 0.606 (P = 0.112, 95 per cent c.i. 0.483-0.729). Similarly, the Hardman Index failed to predict postoperative mortality accurately (P = 0.211, chi(2) for trend). Of nine patients in this series with three or more Hardman criteria, generally held to be fatal, six survived. CONCLUSION: Contrary to previous reports, The Glasgow Aneurysm Score and the Hardman Index were poor predictors of postoperative mortality after repair of a ruptured AAA in this study.     

Predictors of Early Discharge following Open Abdominal Aortic Aneurysm Repair

Patients undergoing endovascular abdominal aortic aneurysm (AAA) repair have lower perioperative morbidity and leave the hospital earlier than patients undergoing open repair. However, potential complications require continuous surveillance of endografts and there are few data regarding their long-term fate. If an open operation were well tolerated, this might be a preferable alternative. The purpose of this study was to identify patients with lower morbidity and shorter hospital stay following open AAA repair and to analyze factors that might point to open repair as the preferred approach. We performed a retrospective review of all patients who underwent AAA repair between 1995 and 2000 at our institution. All patients with ruptured aneurysms and those that required renal, celiac, or superior mesenteric reconstructions during the AAA repair were excluded. Patient demographics, preoperative comorbid conditions, intraoperative data, and postoperative complications were analyzed in detail. A total of 115 patients fulfilled the inclusion criteria. There was only one perioperative death (0.9%). The mean hospital stay was 8.1 days. A history of chronic obstructive pulmonary disease (COPD) and longer operative time were independent factors associated with prolonged hospital stay. Forty-one patients (35.6%) left the hospital in 5 or less days. Compared to the group with hospital stay >5 days, these patients had a lower incidence of COPD (7.3% vs. 25.7%, p < 0.05) and smaller-size AAAs (5.6 vs. 6.4 cm, p < 0.0001), and were more often operated on via a retroperitoneal approach (61% vs. 40.5%, p < 0.05). Their time in the operating room was less (3.5 vs. 4.5 hr, p < 0.0001), and they had less estimated blood loss (750 vs. 1500 cc, p < 0.001) and fewer transfusions (0.95 vs. 2.45 units, p < 0.0001). Patients without COPD and smaller AAAs that can be repaired via a retroperitoneal approach have a lower incidence of perioperative complications and a shorter hospital stay following open AAA repair. Until long-term results for endografts are available, our data suggest that these patients are well served with an open repair.     

Baseline oxygen delivery is associated with an increased risk of severe postoperative complications after elective open repair of abdominal aortic aneurysm

AIM: Oxyhemodynamic parameters have been shown to have a relevant impact on the immediate postoperative outcome after major surgery, but it is not known their specific impact on the outcome after elective repair of abdominal aortic aneurysm (AAA). METHODS: One-hundred and forty-one patients underwent elective open repair of infrarenal AAA and hemodynamic parameters were monitored perioperatively. RESULTS: One patient (0.7%) died postoperatively, 23 (16.3%) experienced a myocardial ischemic event and 9 of them (6.4%) had a myocardial infarction. Baseline oxygen delivery was not predictive of such myocardial ischemic events. Thirty-three patients (23.4%) suffered severe postoperative complications. The median baseline oxygen delivery was 429.5 mL/min/m2 among patients who had severe postoperative complications, whereas it was 505.5 mL/min/m2 among those who did not have severe complications (p=0.03). However, this parameter did not retain its significance at multivariate analysis. When only the preoperative variables were included in the logistic regression model, the Glasgow Aneurysm Score (P=0.004, Oddsratio 1.94, 95% C.I. 1.24-3.05) was the only predictor of severe postoperative complications. The Glasgow Aneurysm Score was significantly correlated with baseline oxygen delivery (P=-0.256, P=0.003). CONCLUSIONS: Baseline oxygen delivery is associated with an increased risk of severe postoperative complications after elective open repair of AAA. The value of preoperative optimization of oxygen delivery should be evaluated in this patient population.     

Peroperative factors influencing the outcome of elective abdominal aorta aneurysm repair.

PURPOSE: To identify perioperative variables which may influence mortality of elective abdominal aneurysm repair (AAA). METHOD: prospective study of patients undergoing elective AAA repair between 1986 and 1997. RESULTS: Four hundred and seventy patients (438 men, 32 females) with a mean age of 69.4+/-13 years and aneurysms with a diameter of 60+/-3 mm were operated on with a 1-month mortality rate of 5.3%. Multivariate analysis identified the following independent risk factors for mortality: age >70 (p<0.0001), a past history of myocardial infarction (p<0.0001), preoperative renal insufficiency (p<0.0001), reoperation (p<0.0001), colonic necrosis (p<0.0001), and severe postoperative medical complications (p<0.0001). CONCLUSION: Intra- and postoperative events affect the outcome of AAA repair, independently of preoperative factors, and should be described when presenting the results of AAA repair.     

The Glasgow Aneurysm Score as a tool to predict 30-day and 2-year mortality in the patients from the Dutch Randomized Endovascular Aneurysm Management trial

OBJECTIVE: Randomized trials have shown that endovascular repair (EVAR) of an abdominal aortic aneurysm (AAA) has a lower perioperative mortality than conventional open repair (OR). However, this initial survival advantage disappears after 1 year. To make EVAR cost-effective, patient selection should be improved. The Glasgow Aneurysm Score (GAS) estimates preoperative risk profiles that predict perioperative outcomes after OR. It was recently shown to predict perioperative and long-term mortality after EVAR as well. Here, we applied the GAS to patients from the Dutch Randomized Endovascular Aneurysm Repair (DREAM) trial and compared the applicability of the GAS between open repair and EVAR. METHODS: A multicenter, randomized trial was conducted to compare OR with EVAR in 345 AAA patients. The GAS was calculated (age + [7 points for myocardial disease] + [10 points for cerebrovascular disease] + [14 points for renal disease]). Optimal cutoff values were determined, and test characteristics for 30-day and 2-year mortality were computed. RESULTS: The mean GAS was 74.7 +/- 9.3 for OR patients and 75.9 +/- 9.7 for EVAR patients. Two EVAR patients and eight OR patients died < or =30 days postoperatively. The area under the receiver-operator characteristic curve (AUC) was 0.79 for OR patients and 0.87 for EVAR patients. The optimal GAS cutoff value was 75.5 for OR and 86.5 for EVAR. By 2 years postoperatively, 18 patients had died in both the EVAR and the OR patient groups. The AUC was 0.74 for OR patients and 0.78 for EVAR patients. The optimal GAS cutoff value was 74.5 for OR and 77.5 for EVAR. CONCLUSION: This is the first evaluation of the GAS in a randomized trial comparing AAA patients treated with OR and EVAR. The GAS can be used for prediction of 30-day and 2-year mortality in both OR and EVAR, but in patients that are suitable for both procedures, it is a better predictor for EVAR than for OR patients. In this study, the GAS was most valuable in identifying low-risk patients but not very useful for the identification of the small number of high-risk patients.     

External validation of the Glasgow Aneurysm Score to predict outcome in elective open abdominal aortic aneurysm repair

OBJECTIVES: Selecting patients based on their risk profiles could improve the outcome after elective surgery of an abdominal aortic aneurysm (AAA). The Glasgow Aneurysm Score (GAS) is a scoring system developed to determine such risk profiles. In other settings, the GAS has proved to have a predictive value for the postoperative outcome. The aim of this study was to investigate whether the GAS was also valid for the patients in our hospital and to examine risk factors with a possible predictive value for postoperative mortality and morbidity. METHODS: We performed a retrospective cohort study in a university hospital. The medical records of 229 patients who underwent open elective repair for an AAA in the period 1994 to 2003 were retrospectively analyzed to assess the GAS and to determine which of the examined risk factors had a predictive value for the prognosis. RESULTS: Five patients (2.2%) died after surgery and 30 (13.1%) had a major complication. The GAS was predictive for postoperative death (P = .021; sensitivity, 1.00; 95% confidence interval [CI], 0.52 to 1.00; specificity, 0.67; 95% CI, 0.61 to 0.73) and also for major morbidity (P = .029; sensitivity, 0.63; 95% CI, 0.46 to 0.78; specificity, 0.70; 95% CI, 0.64 to 0.76). The positive predictive value (mortality, 0.06; morbidity, 0.24) and the positive likelihood ratio (mortality, 3.07; morbidity, 2.14) were low, however. The best cutoff value for the GAS was determined at 77. All the deceased patients (100%) and 63.3% of those who had a major complication had a risk score of >or=77. Of all examined risk factors, suprarenal clamping during surgery was predictive of in-hospital mortality (8.3%, P = .017). For major morbidity, three risk factors, all of which are components of the GAS, were predictive: age (P = .046), cardiac disease (P = .032), and renal disease (P = .041). CONCLUSIONS: The Glasgow Aneurysm Score has a predictive value for outcome after open elective AAA repair. Because of its relatively low positive predictive value for death and major morbidity, the GAS is of limited value in clinical decision-making for the individual high-risk patient. In some particular cases, however, the GAS can be a useful tool, especially for low-risk patients because it has good negative predictive value for this group. Suprarenal clamping was found to be a risk factor for postoperative death.     

Endovascular versus "fast-track'' abdominal aortic aneurysm repair

Recent studies have shown that endovascular abdominal aortic aneurysm repair (EVAR) has decreased costs, as well as decreased intensive care unit and total hospital length of stays when compared to abdominal aortic aneurysm (AAA) repair using a retroperitoneal exposure. The authors hypothesized that the fast-track AAA repair, which combines a retroperitoneal exposure with a patient care pathway that includes a gastric promotility agent and patient-controlled analgesia, would have no differences when compared to EVAR. Records of 58 patients who underwent AAA repair between April 14, 2000, and July 12, 2002, were reviewed retrospectively. Demographic information, length of stay, intraoperative and postoperative complications, mortality, and costs were evaluated. Fifty-eight AAA repairs were performed with the EVAR (n=28) and fast-track (n=30) techniques. The EVAR group was slightly older (72 vs 68 years, p=0.04), had slightly smaller average aneurysm size (5.5 +/-0.13 vs 6.1 +/-0.17 cm, p=0.008), and had more patients designated American Society of Anesthesia class 4 (p<0.0001). Both groups were predominantly male. Otherwise there were no statistically significant differences in risk factors. Patients who underwent fast-track repair tended to have a longer operation (216 +/-7.4 vs 158 +/-6.8 minutes, p<0.0001), with a greater volume of blood (1.8 +/-0.29 vs 0.32 +/-0.24 units, p=0.0005), colloid (565 +/-89 vs 32 +/-22 cc, p<0.0001), and crystalloid transfusions (4,625 +/-252 vs 2,627 +/-170 cc, p<0.0001). There were no statistically significant differences in the number of intraoperative or postoperative complications between the 2 groups. EVAR patients resumed a regular diet earlier (0.21 +/-0.08 vs 1.8 +/-0.11 days, p<0.0001). Intensive care unit stay was shorter for EVAR (0.50 +/-0.10 vs 0.87 +/-0.10 days, p=0.01), but floor (2.1 +/-0.23 vs 2.6 +/-0.21 days, p=0.17), and total hospital lengths of stay (2.8 +/-0.32 vs 3.4 +/-0.18 days, p=0.07) were similar between the 2 groups. Total hospital cost was lower in the fast-track (10,205 dollars +/-736 dollars vs 20,640 dollars +/- 1,206 dollars, p<0.0001) leading to greater overall hospital earnings (6,141 dollars +/- 1,280 dollars vs 107 dollars +/- 1,940 dollars, p=0.01). Fast-track AAA repair is a viable alternative for the treatment of abdominal aortic aneurysms. Compared to endovascular repair, the fast-track method had increased transfusions of blood and intravenous fluids and increased operating room times, but equivalent lengths of floor and total hospital stay and increased total hospital earnings.     

Preoperative risk stratification in patients undergoing elective infrarenal aortic aneurysm surgery: evaluation of five risk scoring methods.

OBJECTIVE: To evaluate five risk scoring methods in predicting the immediate postoperative outcome after elective open repair of abdominal aortic aneurysm (AAA). DESIGN: Retrospective evaluation of the Eagle score, Glasgow aneurysm score, Leiden score, modified Leiden score and Vanzetto score in a consecutive series of patients. PATIENTS: Two hundred and eighty-six consecutive patients undergoing elective infrarenal aortic aneurysm repair. RESULTS: Nine patients (3.1%) died in hospital and another 35 (12%) experienced severe postoperative complications. For the Glasgow aneurysm score, Leiden score, modified Leiden score and Vanzetto score receiver operating characteristics (ROC) curve analysis for prediction of in-hospital mortality showed area under the curve (AUC) of 0.749 (p=0.01), 0.777 (p=0.008), 0.788 (p=0.006) and 0.794 (p=0.005), respectively. The Eagle risk score was less accurate for predicting in-hospital mortality. The risk-scoring systems did not perform well in predicting post-operative complications, but multivariate analysis showed that the modified Leiden score was an independent predictor of postoperative complications. CONCLUSION: All scoring systems predict, with reasonable accuracy, the risk of in-hospital death in patients undergoing elective open repair of AAA, whereas the accuracy in predicting severe postoperative complications is less.     

Minimal incision aortic surgery.

PURPOSE: In this study we evaluated the clinical and economic impact of minimal incision aortic surgery (MIAS) for treatment of patients with abdominal aortic aneurysms (AAAs) and aortoiliac occlusive disease (AIOD). METHOD: Fifty patients with either AAA (34) or AIOD (16), prospectively treated with the MIAS technique, were compared with 50 patients (40 AAA and 10 AIOD) treated in the same time period with long midline incision and extracavitary small bowel retraction. MIAS was also compared with a cohort of 32 patients with AAA treated by means of endoaortic stent-grafts. Outcomes and cost (based on metric mean length of stay) were compared for the open and endoaortic techniques. RESULTS: Patients who experienced no perioperative complications after the MIAS or endovascular repair technique had shorter hospital stays than patients with uncomplicated aortic repairs performed with a traditional long midline abdominal incision (3 days vs 3 days vs. 7.2 days). Hospital stay was also significantly shorter for the less invasive procedures when perioperative complications were included (4.8 days vs. 4.3 days vs 9.3 days). The MIAS and endovascular aortic repair groups had a shorter intensive care unit stay (< or = 1.0 day) and a quicker return to general dietary feeding (2.5 days) than patients treated with standard open repair (1.8 days, 4.7 days). The overall morbidity for the MIAS technique (14%) and endovascular technique (21%) was not significantly different from standard open repair (24%). The mortality rate for the different treatment groups was equivalent (MIAS, 2%; endovascular repair, 3%; standard repair, 2%). The MIAS was more cost-efficient than standard open repair ($12,585 vs $18,445) because of shorter intensive care unit and hospital stay and was more cost-efficient than endoaortic repair ($12,585 vs $32,040) because of reduced, direct intraoperative costs. CONCLUSIONS: MIAS is as safe as standard open or endovascular repair in the treatment of AAA and AIOD. MIAS is more cost-efficient than standard open or endoaortic repair.     

Glasgow Aneurysm Score predicts survival after endovascular stenting of abdominal aortic aneurysm in patients from the EUROSTAR registry

BACKGROUND: The aim of the present study was to evaluate the efficacy of the Glasgow Aneurysm Score (GAS) in predicting the survival of 5498 patients who underwent endovascular repair (EVAR) of an abdominal aortic aneurysm (AAA) and were enrolled in the EUROpean collaborators on Stent-graft Techniques for abdominal aortic Aneurysm Repair (EUROSTAR) Registry between October 1996 and March 2005. METHODS: The GAS was calculated in patients who underwent EVAR and was correlated to outcome measurements. RESULTS: The median GAS was 78.8 (interquartile range 71.9-86.4, mean 79.2). Tertile 30-day mortality rates were 1.1 per cent for patients with a GAS less than 74.4, 2.1 per cent for those with a score between 74.4 and 83.6, and 5.3 per cent for patients with a score over 83.6 (P < 0.001). Multivariate analysis showed that GAS was an independent predictor of postoperative death (P < 0.001). The receiver-operator characteristic curve showed that the GAS had an area under the curve of 0.70 (95 per cent confidence interval 0.66 to 0.74; s.e. 0.02; P < 0.001) for predicting immediate postoperative death. At its best cut-off value of 86.6, it had a sensitivity of 56.1 per cent, specificity 76.2 per cent and accuracy 75.6 per cent. Multivariable analysis showed that overall survival was significantly different among the tertiles of the GAS (P < 0.001). CONCLUSION: The GAS was effective in predicting outcome after EVAR. Because its efficacy has also been shown in patients undergoing open repair of AAA, it can be used to aid decisions about treatment in all patients with an AAA.     

Positive fluid balance is associated with complications after elective open infrarenal abdominal aortic aneurysm repair.

BACKGROUND: Open abdominal aortic aneurysm (AAA) repair is associated with cardiac and respiratory complications and an overall mortality rate of 2 to 8%. We hypothesised that excessive fluid administration during the perioperative period contributes to complications and poor outcome after AAA repair. METHODS: This was a retrospective cohort study. Medical records were analysed for fluid balance and complications in 100 consecutive patients treated by open AAA repair at a single centre between 2002-2005. Mortality and all major adverse events (MAE) such as myocardial infarction (MI), cardiac arrhythmia (Arr), pulmonary oedema (PO), pulmonary infection (PI), and acute renal failure (ARF) were included in the analysis. Level of care and hospital stay, were also recorded. RESULTS: There were no in-hospital deaths. MAE occurred in 40/100 (40%): MI (6%); Arr (14%); PO (14%); PI (25%); ARF (8%). Complications were not predicted by preoperative cardiovascular risk factors, operative and clamp time, or blood loss. Patients with complications had significantly greater cumulative positive fluid balance on postoperative day 0 (p<0.01), day 1 (p<0.05), day 2 (p<0.03) and day 3 (p<0.04). This relationship also existed for individual complications such as MI, and pulmonary oedema. These patients had significantly longer ICU/HDU (p<0.002) and hospital stay (p<0.0001). CONCLUSIONS: Serious complications are common after elective open AAA repair, and we have shown that positive fluid balance is predictive of major adverse events increased HDU/ICU and overall hospital stay.     

Prognostic scoring in ruptured abdominal aortic aneurysm: a prospective evaluation

BACKGROUND: Prospective validation of prognostic scoring systems for ruptured abdominal aortic aneurysm (AAA) is lacking. This study assesses the validity of three established risk scores and a new prognostic index. METHOD: Patients admitted with ruptured AAA during a 26-month period (August 2002-December 2004) were recruited prospectively. The Glasgow Aneurysm Score (GAS), Hardman Index, Physiological and Operative Severity Score for enUmeration of Mortality and Morbidity (POSSUM) scores, and the Edinburgh Ruptured Aneurysm Score (ERAS) were recorded and related to outcome. RESULTS: During the study period, 111 patients were admitted with ruptured AAA. Of these, 84 (76%) underwent attempted operative repair and were included in the study; 37 (44%) died after operation. The GAS, Hardman Index, and the ERAS were statistically related to mortality. However, analysis by receiver-operator characteristic curve revealed the ERAS to have an area under the curve (AUC) of 0.72 (95% confidence interval [CI], 0.61-0.83). The vascular (V)-POSSUM and ruptured AAA (RAAA)-POSSUM models had an AUC of 0.70 (95% CI, 0.59-0.82). The Hardman Index and GAS had an AUC of 0.69 (95% CI, 0.57-0.80) and 0.64 (95% CI, 0.52-0.76), respectively. Although the V-POSSUM equation predicted mortality effectively (P = .086), the RAAA-POSSUM derivative demonstrated a significant lack of fit (P = .009). CONCLUSION: Prospective validation shows that the Hardman Index, GAS, and V-POSSUM and RAAA-POSSUM scores do not perform well as predictors for death after ruptured AAA. The ERAS accurately stratifies perioperative risk but requires further validation.     

Infrarenal Abdominal Aortic Aneurysm Repair via Endovascular Versus Open Retroperitoneal Approach

The beneficial effects of open surgical abdominal aortic aneurysm (AAA) repair via a left retroperitoneal approach have been established. We compared the short-term outcome of infrarenal AAA repair via an endovascular approach with that of an open retroperitoneal approach. From October 2001 to April 2003, patients with infrarenal AAA >5 cm were offered repair via an endovascular approach (group I) with a variety of industry-made stent grafts or with an open retroperitoneal surgical approach (group II). Data were prospectively collected in the vascular registry and complications were analyzed. Data comparison between the two groups was done by using chi-squared analysis and two-tailed Students t-test. Statistical significance was identified at p < 0.05. Over an 18-month period, 492 patients underwent evaluation for AAA. Of these, 446 patients had infrarenal AAA and underwent either endovascular (group I: n=175, male 85%, female 15%) or open surgical repair (group II: n=232, male 74%, female 26%) via a left retroperitoneal approach. Group I patients had a higher incidence of coronary artery disease (66% vs. 35%, p < 0.05), hypertension (74% vs. 43%, p < 0.05), chronic obstructed pulmonary disease (29% vs. 12%, p < 0.05), and diabetes mellitus (20% vs. 7%, p < 0.05), a lower mean amount of intraoperative blood loss (277 cc vs. 1452 cc, p < 0.05), and shorter length of stay in the hospital (1.7 days vs., 7.3 days, p < 0.05). Group I also had fewer complications of myocardial infarction (1.7% vs. 5.2%, p=NS), renal failure (0% vs. 2.6%, p < 0.05), pulmonary failure (1.7% vs. 2.6%, p=NS), ischemic colitis requiring colectomy (0.6% vs. 2.6%, p < 0.05), multisystem organ failure (0% vs. 1.3%, p=NS), and death (0.6% vs. 1.3%, p < 0.05). Despite increased preexisting comorbidities, patients undergoing endovascular aneurysm repair had less morbidity, mortality, and blood loss and a shorter in-hospital length of stay than patients undergoing open surgical aneurysm repair via a left retroperitoneal approach.Presented at the 28th Annual Meeting of the Peripheral Vascular Surgery Society, Chicago, IL, June 7, 2003.     

Historic control comparison of outcome for matched groups of patients undergoing endoluminal versus open repair of abdominal aortic aneurysms

Purpose: Currently no randomized studies show the relative morbidity and mortality of the open and endoluminal methods of abdominal aortic aneurysm (AAA) repair. The aim of this study was to analyze the outcome of two matched groups of patients with AAA, one undergoing open repair and the other undergoing endoluminal repair.Methods: Two groups of patients who had undergone repair of AAA by open technique (group 1) or by endoluminal methods (group 2) were compared. A historic control cohort of 27 patients was selected from 56 consecutive patients who underwent open repair of AAA between January 1991 and February 1992. Patients considered unsuitable for the endoluminal method on the basis of computed tomography and aortography were excluded (n = 29). Between May 1992 and November 1994 prospective data were recorded for 62 consecutive patients who underwent endoluminal repair by tube or bifurcated endografts. Twenty-eight patients who had been specifically referred for endoluminal AAA repairs because of preexisting severe medical comorbidities were excluded. Six of the endoluminal cases had failure, requiring conversion to open operation, and were excluded for separate analysis, leaving 28 patients in group 2. Patients in both groups were thus fit and suitable for either open or endoluminal repair and were comparable in relation to age, sex, risk factors, dimensions, and form of AAA.Results: The mean values for operation time, blood loss, intensive care stay, and hospital stay for group 1 and group 2 were 2.6 versus 3.1 hours, 1422 versus 873 ml,* 1.8 versus 0.7 days,* and 12.4 versus 11.1 days, respectively (*p < 0.05). Local/vascular complications occurred in 15% of patients in group 1 compared with 25% in group 2 (p = 0.55), whereas remote/systemic complications occurred in 37% and 29%, respectively (p = 0.3). Five of 28 patients in the endoluminal group had complications requiring early operative repair (n = 3) or late revision (n = 2). When comparison was made on an intention-to-treat basis (with failed procedures included), the incidence of local/vascular complications was significantly greater for endoluminal repair (p = 0.047).Conclusions: The incidence of systemic/remote complications was similar for the two groups in spite of significantly less blood loss and shorter intensive care unit stay with endoluminal repair. The incidence of local/vascular complications had a tendency to be higher for endoluminal compared with standard open method (and was significantly greater if failed procedures were included). In this early experience with prototype devices, patients who were medically suitable for open surgical procedures did not derive benefit from the less invasive endoluminal technique with respect to duration of operation, length of hospital stay, or perioperative morbidity and mortality. On the other hand, because they also did not have worse outcome, a randomized study is now justified in this group. (J VASC SURG 1996;23:201-12.)