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.     

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.     

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.     

Glasgow Aneurysm Score in Patients Undergoing Elective Open Repair of Abdominal Aortic Aneurysm: A Finnvasc Study

OBJECTIVE: To use Finnvasc to determine whether the Glasgow Aneurysm Score predicts postoperative outcome after open repair of abdominal aortic aneurysm (AAA). DESIGN: Retrospective study. MATERIAL AND METHODS: The operative risk of 1911 patients undergoing open repair of AAA was retrospectively graded according to the Glasgow Aneurysm Score. RESULTS: At 30 days 100 (5%) patients had died and 21% had developed severe postoperative complications. Receiver operating characteristics (ROCs) curve analysis showed that the Glasgow Aneurysm Score was predictive of postoperative mortality (area under the curve (AUC): 0.668, p<0.0001), severe complications (AUC: 0.654, p<0.0001), cardiac complications (AUC: 0.689, p<0.0001) and intensive care unit stay >5 days (AUC: 0.634, p<0.0001). Patients scoring >76 had significantly higher mortality (9% vs. 3%, p<0.0001), severe (31% vs. 15%, p<0.0001) and cardiac complications (12% vs. 4%, p<0.0001) and intensive care unit stay >5 days (12% vs. 6%, p<0.0001). CONCLUSIONS: The Glasgow Aneurysm Score is a rather good predictor of immediate postoperative mortality and morbidity after elective open repair of AAA.     

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.     

External validation of Vascular Study Group of New England risk predictive model of mortality after elective abdominal aorta aneurysm repair in the Vascular Quality Initiative and comparison against established models

Objective

The purpose of this study is to externally validate a recently reported Vascular Study Group of New England (VSGNE) risk predictive model of postoperative mortality after elective abdominal aortic aneurysm (AAA) repair and to compare its predictive ability across different patients' risk categories and against the established risk predictive models using the Vascular Quality Initiative (VQI) AAA sample.

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.     

Quantification of mortality risk after abdominal aortic aneurysm repair

BACKGROUND: The study was designed to evaluate the Acute Physiology And Chronic Health Evaluation (APACHE) II risk scoring system in abdominal aortic aneurysm (AAA) surgery. The aim was to create an APACHE-based risk stratification model for postoperative death. METHODS: Prospective postoperative APACHE II data were collected from patients undergoing AAA repair over a 9-year interval from 24 intensive care units (ICUs) in the Thames region. A multilevel logistic regression model (APACHE-AAA) for in-hospital mortality was developed to adjust for both case mix and the variation in outcome between ICUs. RESULTS: A total of 1896 patients were studied. The in-hospital mortality rate among the 1289 patients who had elective AAA repair was 9.6 (95 per cent confidence interval (c.i.) 8.0 to 11.2) per cent and that among the 605 patients who had an emergency repair was 46.9 (95 per cent c.i. 43.0 to 50.9) per cent. Four independent predictors of death were identified: age (odds ratio (OR) 1.05 (95 per cent c.i. 1.03 to 1.07) per year increase), Acute Physiology Score (OR 1.14 (95 per cent c.i. 1.12 to 1.17) per unit increase), emergency operation (OR 4.86 (95 per cent c.i. 3.64 to 6.52)) and chronic health dysfunction (OR 1.43 (95 per cent c.i. 1.04 to 1.97)). The APACHE-AAA model was internally valid, as shown by calibration (Hosmer-Lemeshow C statistic: chi(2) = 6.14, 8 d.f., P = 0.632), discrimination properties (area under receiver-operator characteristic curve 0.845) and subgroup analysis. There was no significant variation in outcome between hospitals. CONCLUSION: APACHE-AAA was shown to be an accurate risk-stratification model that could be used to quantify the risk of death after AAA surgery. It might also be used to determine the relative impact of ICU over high-dependency unit care.     

Optimal timing of abdominal aortic aneurysm repair after coronary artery revascularization.

OBJECTIVE: The authors ascertained the optimal timing of repair of an abdominal aortic aneurysm (AAA) after coronary artery revascularization. SUMMARY BACKGROUND DATA: Cardiac events are the most common cause of death after elective repair of AAA. Preoperative coronary revascularization has significantly reduced postoperative cardiac complications after elective AAA repair. Currently, most patients undergo repair of asymptomatic AAA within 6 months after the coronary revascularization. METHODS: The authors performed a retrospective review of patients who underwent repair or scheduled repair of an asymptomatic AAA within 6 months after coronary artery bypass graft (CABG) between March 1988 and October 1993. RESULTS: There was no mortality in the group of patients (n = 14) who underwent repair of AAA simultaneously or within 14 days of coronary revascularization. In contrast, there was a significantly increased mortality rate of 3 of 9 (33%) in patients scheduled to undergo repair of the AAA more than 2 weeks after coronary revascularization (p < 0.05). All nonsurvivors died between 16 and 29 days after CABG, and died as a result of ruptured AAA. CONCLUSION: Elective AAA repair should be undertaken simultaneously or within 2 weeks of coronary artery revascularization because of an increased risk of postoperative AAA rupture seen after this time period. In addition, simultaneous or early postoperative AAA repair does not increase the overall operative risk.     

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.     

An analysis of risk factors of perioperative bleeding in surgical repair of abdominal aortic aneurysm

BACKGROUND: In surgical repair of abdominal aortic aneurysm (AAA), excessive bleeding which causes postoperative complications is sometimes observed. To determine the risk factors of perioperative excessive blood loss, this retrospective study was performed. METHODS: Design. A retrospective study. Setting. An academic medical center. Participants. One hundred and forty patients underwent elective surgical repair of an abdominal aortic aneurysm (AAA) at our institution from 1995 through 1997. Measurements. The present study includes critical review of 140 consecutive charts of patients undergoing elective surgical repair of AAA. Preoperative laboratory data, intraoperative data and amount of blood loss to identify risk factors of perioperative blood loss. Factors which were found to be significantly associated with the amount of perioperative blood loss were preoperative plasma fibrin degradation product (FDP) level (r=0.445), amount of immediate re-infusion of shed blood (r=0.438), and duration of operation (r=0.411). RESULTS: Preoperative fibrinogen level correlated with perioperative blood loss little (r=-0.187). Preoperative platelet count or the other coagulation profile did not affect the amount of perioperative blood loss. The patients whose preoperative FDP were more than 40 microg x ml(-1) significantly increased the risk of excessive blood loss compared with less than 40 microg x ml(-1). CONCLUSIONS: The significant preoperative risk factor of perioperative blood loss was only FDP level in present study. Especially, the patients whose preoperative FDP were more than 40 microg x ml(-1) increased the risk of excessive blood loss.     

Indications for the surgical treatment of abdominal aortic aneurysms

BACKGROUND: On the basis of a literature review and of personal experience, the authors analyze the main indications and the best strategy for elective surgical repair of infrarenal abdominal aortic aneurysm (AAA). METHODS: Personal experience concerning elective surgical treatment of 110 patients with infrarenal AAA, is presented. RESULTS: No operative deaths have been observed and the postoperative recovery was regular in 108 patients. Two early complications (colon ischemia) and ten late postoperative complications (5 pseudoaneurysms, 5 sexual dysfunctions) occurred. CONCLUSIONS: The main therapeutic guidelines concerning the management of AAA should follow specific indications (aneurysm dimensions and growth rates). Indications for operative repair of aneurysms obviously should be judged in relation to the presence or absence of associated risk factors or concomitant medical conditions. In most cases, aneurysm repair can be performed safely, despite associated medical risks, by careful preoperative evaluation and preparation.     

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.     

Estimation of physiologic ability and surgical stress (E-PASS) as a predictor of immediate outcome after elective abdominal aortic aneurysm surgery

BACKGROUND: The Estimation of Physiologic Ability and Surgical Stress (E-PASS) score was designed on the premise that the balance between the patient's physiologic reserve capacity and the surgical stress inflicted at operation was important in the occurrence of postoperative complications. The aim of this study was to assess its value in predicting mortality and morbidity after open elective abdominal aortic aneurysm (AAA) repair. METHODS: E-PASS data items were collected prospectively in a group of 204 patients undergoing elective open AAA repair over a 6-year period. The operative morbidity and mortality rates were compared with the preoperative risk score (PRS), surgical stress score (SSS) and comprehensive risk score (CRS) of E-PASS. The group comprised 180 (88%) males and the median age was 73 (range 44 to 86) years. RESULTS: There were 13 (6%) deaths and 121 (59%) experienced a postoperative complication. As the PRS, SSS and CRS increased, the incidence of postoperative morbidity and mortality significantly increased (P < .0001). Overall mean CRS was .52 (+/-.27). Mean CRS in the groups of patients who survived and died were .49 (+/-.24) and .98 (+/-26), respectively. PRS, SSS, and CRS all had extremely good predictive power for both mortality and morbidity as demonstrated by high areas under the receiver operator curve (range .799 to .953). CRS also showed a strong statistically significant association with the severity of postoperative complication (P < .0001) and length of hospital stay (P < .0001). CONCLUSIONS: The E-PASS model appears to be a promising method of predicting death and the development of postoperative complications in patients undergoing elective open AAA surgery. It requires further validation in arterial surgery at different geographical locations.     

Objective scoring systems of medical risk: a clinical tool for selecting patients for open or endovascular abdominal aortic aneurysm repair

BACKGROUND: Objective scoring systems have been developed for risk stratification of open infrarenal aneurysm repair. To date, none have been applied for the selection of patients who would most benefit from either an open or an endovascular approach. This study assessed the utility of comorbidity-based objective scoring systems for defining subgroups of patients who might most benefit from open or endovascular aneurysm repair. METHODS: A retrospective database review was performed for the period January 1999 to December 2004 to identify patients who had undergone elective open aneurysm repair (open repair) or elective endovascular aneurysm repair (EVAR). Validation of the Glasgow Aneurysm Score (GAS), the Modified Leiden Score (M-LS), and the Modified Comorbidity Severity Score (M-CSS) was performed for perioperative mortality risk in the open repair group. GAS, M-LS, and M-CSS were then calculated for the EVAR group. Differences in open repair vs EVAR mortalities were evaluated. RESULTS: During the time period, 558 patients underwent open repair and 304 underwent EVAR. Overall mortality was 4.7% for open repair patients and 2.0% for EVAR. All three scoring systems were validated to our open repair data set (C statistic: GAS, 0.72; M-LS, 0.71; M-CSS, 0.74). A score was calculated for each system that separated patients into groups of either low or high risk of death for open repair. This score (cut point) was 76.5 for the GAS, 5.2 for the M-LS, and 8 for the M-CSS. Analysis of the EVAR population revealed that patients at low medical risk for open repair did not derive statistically significant mortality benefit with EVAR; however, patients at high medical risk for open repair derived significant benefit from EVAR (GAS>76.5 mortality: open repair, 7.8%; EVAR, 1.9% [P<.01]; M-LS mortality: open repair, 8.1%; EVAR, 2.5% [P<.01]; and M-CSS mortality: open repair, 10.3%; EVAR, 3.4% [P<.025]). Despite a very small number of deaths (n=6), receiver operator curve analysis identified M-LS and M-CSS as having some predictive ability for mortality risk with EVAR (C statistic: M-LS, 0.70; M-CSS, 0.69). CONCLUSION: Three validated objective scoring systems can be used to categorize patients into two groups of medical risk: one that has excellent outcome with open repair and derives no early mortality benefit from EVAR, and another that has significant mortality with open repair and derives important benefit with EVAR.     

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.     

Ruptured inflammatory abdominal aortic aneurysm: insights in clinical management and outcome

BACKGROUND: Ruptured inflammatory abdominal aortic aneurysm (AAA) is relatively rare, and little has been written on the outcome of operative treatment. METHODS: Patients undergoing attempted repair of ruptured inflammatory AAA between 1995 and 2001 were included in a retrospective case-cohort study. Demographic, clinical, and operative factors were analyzed, together with in-hospital morbidity, in-hospital mortality, and duration of postoperative hospital stay. RESULTS: Of 297 patients who underwent attempted operative repair of ruptured AAA, 24 (8%) had an inflammatory aneurysm. Twenty-two patients were men, and two were women; median age was 69 years (range, 51-85 years). Operative findings revealed a contained hematoma in 16 patients (70%), free rupture in 3 patients (13%), aortocaval fistula in 4 patients (17%), and aortoenteric fistula in 1 patient (4%). Of 273 noninflammatory ruptured AAAs, only 2 AAA (1%) were associated with primary aortic fistula. Ten patients (42%) with inflammatory AAA died in hospital, compared with 117 of 273 patients (43%) without inflammation. Median postoperative stay was 10 days (range, 0-35 days). Of the 14 patients with inflammatory lesions who survived, 11 had postoperative complications; 4 patients had acute renal failure, three of whom required temporary renal replacement therapy. CONCLUSIONS: Ruptured inflammatory AAA is associated with a higher incidence of aortic fistula than is ruptured noninflammatory AAA. Repair of ruptured inflammatory AAA is not associated with increased operative mortality compared with repair of ruptured noninflammatory AAA.     

VBHOM, a data economic model for predicting the outcome after open abdominal aortic aneurysm surgery

BACKGROUND: Vascular Biochemistry and Haematology Outcome Models (VBHOM) adopted the approach of using a minimum data set to model outcome. This study aimed to test such a model on a cohort of patients undergoing open elective and non-elective abdominal aortic aneurysm (AAA) repair. METHODS: A binary logistic regression model of risk of in-hospital mortality was built from the 2002-2004 submission to the UK National Vascular Database (NVD) (2718 patients). The subset of NVD data items used comprised serum levels of urea, sodium and potassium, haemoglobin, white cell count, sex, age and mode of admission. The model was applied prospectively using Hosmer-Lemeshow methodology to a test data set from the Cambridge Vascular Unit. RESULTS: The validation set contained 327 patients, of whom 208 had elective AAA repair and 119 had emergency repair of a ruptured AAA. Outcome following elective and non-elective AAA repair could be described accurately using the same model. The overall mean predicted risk of death was 14.13 per cent, and 48 deaths were predicted. The actual number of deaths was 53 (chi(2) = 8.40, 10 d.f., P = 0.590; no evidence of lack of fit). The model also demonstrated good discrimination (c-index = 0.852). CONCLUSION: The VBHOM approach has the advantage of using simple, objective clinical data that are easy to collect routinely. The VBHOM data items potentially allow prediction of risk in an individual patient before aneurysm surgery.     

Validation of two risk models for perioperative mortality in patients undergoing elective abdominal aortic aneurysm surgery

The authors validated 2 clinical risk models for perioperative mortality in patients scheduled for elective open abdominal aortic aneurysm surgery (AAA surgery). They studied 361 patients who underwent elective AAA surgery between 1991 and 1999 (validation population). Two clinical risk models were validated. The first was developed in 238 patients from Leiden University Hospital (Leiden risk model). The Leiden risk model was modified to provide predictions for the validation population based on 6 predictors including age, gender, a history of previous myocardial infarction, congestive heart failure, renal disease, and pulmonary disease. The second was a recently published simpler risk model developed in 820 patients in the UK Small Aneurysm Trial (UK risk model) and included 3 predictors (age and renal and pulmonary comorbidity). Logistic regression was used to quantify the relationship between predictors and outcome (mortality within 30 days of surgery). Validation further included the concordance statistic (c-statistic) for discriminative ability and the Hosmer-Lemeshow test for model reliability. The perioperative mortality in the validation population was 6.6% (24/361). Predictors had similar odds ratios, with particularly strong effects of congestive heart failure, pulmonary disease, and renal impairment. The Leiden risk model had reasonable good ability (c-statistic 0.72) and showed adequate calibration (chi(2)=3.3, p=0.97). It could particularly identify a low-risk group. The UK risk model did not perform well (c-statistic 0.60), showing statistically significant lack of fit (chi(2)=64.9, p<0.001). This study showed similar predictive ability of previously identified predictors for perioperative mortality. The Leiden risk model could identify a low-risk group, while the UK risk model showed a relatively poor performance. The current study supports the use of the Leiden model for preoperative risk assessment.     

Review of a routine test of cardiac function before aortic aneurysm surgery

The majority of vascular surgeons employ tests of cardiac function prior to embarking on elective abdominal aortic aneurysm (AAA) repair. This study reviewed the value of measuring preoperative ventricular ejection fraction (VEF). The records of the 207 patients considered for elective AAA repair between 1994 and 2000 were reviewed. In patients who underwent surgery, morbidity and mortality data were retrieved from the vascular department database. These outcomes were correlated with the measured VEFs. In patients turned down for surgery, the reasons were determined from patients' notes, and the role that VEF played in the decision was evaluated. Low VEF did not correlate with postoperative cardiac morbidity or mortality. The range of VEF values in patients turned down for surgery was not significantly different from those who underwent AAA repair. VEF was pivotal in the decision not to operate in only one patient over the 6-year interval. This review found no evidence that routine measurement of VEF prior to elective AAA repair was valuable either in making the decision whether to operate or in predicting outcome and complications. Little or no information was added that could not be gained on simple clinical evaluation of cardiac function.