Perioperative myocardial injury after elective open abdominal aortic aneurysm repair predicts outcome.

OBJECTIVE: Myocardial injury, detected by rises in cardiac troponin I (TnI), is common and associated with decreased survival following open AAA surgery. We examined the relationship between perioperative myocardial injury and postoperative outcome. DESIGN: Observational Cohort Study. METHODS: Forty-three consecutive patients who underwent elective open AAA repair were screened for perioperative myocardial injury or infarction using serial TnI measurements (taken on days 1, 3, and 7), ECG and clinical assessment. The primary outcome was survival free of cardiac failure, or myocardial infarction (MI) at follow-up. RESULTS: Twenty (47%) of the 43 patients had a TnI elevation. Of these, 11 (26%) patients met the criteria for MI. At a mean (+/-SD) follow-up of 1.5+/-0.8 years, 12 (28%) subjects had experienced at least one endpoint event. Survival free of cardiac failure or MI was 55% in patients who had TnI rises compared to 87% in those without (P=0.02). Logistic regression revealed that TnI elevation was an independent predictor of outcome with an odds ratio of 5.4 (95% CI 1.2-2.4, P=0.03). CONCLUSION: Perioperative myocardial injury after elective open AAA repair predicts outcome after surgery. Routine TnI measurement should be considered in all patients, especially in those with high cardiovascular risk.     

Recurrent symptomatic aortic sac seroma after open abdominal aortic aneurysm repair

The expansion of an abdominal aortic aneurysm sac after conventional repair has been rarely described. All cases in the literature have been associated with polytetrafluoroethylene grafts and perigraft seromas. We present a patient with a recurrent, symptomatic periaortic graft seroma after conventional repair. The etiology of this problem along with its potential increasing significance in the endovascular era is reviewed.     

Functional outcome after open repair of abdominal aortic aneurysm

INTRODUCTION: Detailed information on functional outcome after open abdominal aortic aneurysm (AAA) repair is sparse. Information about functional outcome of open AAA repair is essential to allow comparison of treatment modalities. METHODS: To determine the functional outcome of patients after open repair of AAA, we reviewed 154 consecutive, nonemergency open repairs of infrarenal AAAs between 1990 and 1997 and each patient's medical records. Clinical variables were recorded for each patient, as were multiple outcomes, including ambulatory status, independent living status, current medical condition, and the patient's perception of recovery and satisfaction. Eighty-seven patients or their families were available for current telephone interview to obtain information about objective functional activities, including walking and driving, and subjective functional information, including assessment of complete recovery and willingness to undergo AAA repair again. Chart data were available for all 154 patients. RESULTS: There were 42 women and 112 men. A total of 139 operations were elective, and 15 were urgent. The operative mortality rate was 4%, mean hospital stay was 10.7 +/- 1.3 days, and mean intensive care unit stay was 4.57 +/- 1.17 days. Seventeen (11%) patients required transfer to a skilled nursing facility with a mean stay of 3.66 +/- 2.9 months. All patients were ambulatory preoperatively, whereas at last follow-up (median, 25 months; range, 0.13-108.5 months), 100 (64%) of the patients remained ambulatory, 34 (22%) required assistance, and 12 (14%) were nonambulatory. At current assessment by telephone interview, 33% of patients described a decrease in their functional activity including driving, shopping, and traveling compared with their preoperative status, whereas 67% were unchanged. When asked to assess their own degree of recovery, 64% of patients stated that they experienced complete recovery with an average time to recovery of 3.9 months, whereas 33% said they had not fully recovered at a mean follow-up of 34 months. Sixteen (18%) patients said they would not undergo AAA repair again knowing the recovery process, even though they appeared to fully understand the implication of AAA rupture. CONCLUSION: Patients undergoing open AAA repair generally experienced significant freedom from surgical complications. However, substantial functional impairment was present. It is unclear whether the functional disability resulted from the AAA surgery or from aging and comorbidities unrelated to surgery.     

Outcome of symptomatic, unruptured abdominal aortic aneurysms after endovascular repair with the Zenith stent-graft system

OBJECTIVE: Symptomatic abdominal aortic aneurysms (AAA) account for up to 20% of patients with unruptured AAA undergoing open repair. This condition is associated with an average postoperative mortality rate after open repair of about 16%. The aim of this study was to evaluate the outcome of a consecutive series of patients who underwent endovascular repair for symptomatic, unruptured AAA. MATERIAL AND METHODS: From January 2000 to October 2006, 14 patients underwent endovascular repair of intact AAA within 15 days since admission for AAA-related symptoms. In these patients, a Zenith stent-graft (Cook Incorporated, Bloomington, IN, USA) was deployed at the Oulu University Hospital, Kuopio University Hospital and Helsinki University Hospital, Finland. RESULTS: Stent-grafting was not successful in one patient because of access failure. The procedure was immediately converted to open repair and an aortobifemoral bypass with a Dacron prosthesis was performed. In the remaining 13 patients, bifurcated Zenith stent-grafts were deployed. After the procedure, type II endoleak was observed in three patients. The mean follow-up time was 1.9+/-1.4 years. The 2-year survival rate was 69%. The survival freedom from secondary procedure was 71% as one patient underwent stent-grafting for a distal type I endoleak 5 months after the procedure. Another patient underwent femoro-femoral cross-over bypass surgery because of right limb graft thrombosis which occurred 9 months after the procedure. CONCLUSIONS: These preliminary results suggest that endovascular repair of symptomatic, unruptured AAA is feasible and can be associated with a favourable outcome despite a very high operative risk.     

Functional outcome after open repair of ruptured abdominal aortic aneurysm

BACKGROUND: Outcome after operative repair of ruptured abdominal aortic aneurysm (AAA) has traditionally been assessed in terms of survival. This study examines the functional outcome of patients who survive operation. METHODS: Consecutive patients who survived open repair over an 18-month period were entered into a prospective case-control study. Age- and sex-matched controls were identified from patients undergoing elective AAA repair. The Short Form-36 health survey was administered to both groups of patients at 6 months after operation. Results were compared with the expected scores for an age- and sex-matched normal UK population. RESULTS: Fifty-seven patients underwent open repair of a ruptured AAA, and 30 survived; no patient was lost to follow-up. There were no significant differences in quality of life between patients who had an emergency repair and those who had an elective repair. Both of these groups had poorer health-related quality of life outcomes than the matched normal population. Surprisingly, compared with the normal population, patients after elective repair had poorer outcomes in more health domains than patients who survived emergency operation. CONCLUSIONS: Survivors of ruptured AAA repair have a good functional outcome within 6 months of operation.     

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.     

Cardiac troponin I predicts outcome after ruptured abdominal aortic aneurysm repair

BACKGROUND: Cardiac troponin I (cTnI) is a highly sensitive and specific marker for myocardial injury that predicts mortality in patients with acute coronary syndromes. This study examined the relationship between perioperative cTnI levels and clinical outcome in patients with ruptured abdominal aortic aneurysm (AAA). METHODS: Consecutive patients who underwent operative repair of a ruptured AAA over a 22-month interval and survived for more than 24 h were entered into a prospective observational cohort study. Levels of cTnI were measured immediately before, and at 24 and 48 h after surgery, and related to clinical outcome. RESULTS: Of 62 patients who underwent attempted operative repair of ruptured AAA, 50 (81 per cent) survived for more than 24 h and were included in this study. Twenty-three (46 per cent) of the 50 had a detectable cTnI level at one or more time points during the first 48 h. Of these, 11 patients had clinical or electrocardiographic evidence of an acute cardiac event and 12 did not; five patients in each of these two groups died. Of 27 patients with no increase in cTnI in the first 48 h, only three died (P = 0.031 and P = 0.043 respectively, relative to the groups with detectable cTnI). CONCLUSION: Approximately half of patients who survived repair of ruptured AAA for more than 24 h sustained a detectable myocardial injury within the first 48 h. A perioperative increase in the level of cTnI, with or without clinically apparent cardiac dysfunction, was associated with postoperative death.     

Risk-scoring methods in predicting the immediate outcome after emergency open repair of ruptured abdominal aortic aneurysm

BACKGROUND: Rupture of an abdominal aortic aneurysm (RAAA) is associated with a risk of death approaching 80%. Prediction of immediate postoperative death in this condition assumes obvious relevance because it may be helpful in preoperative risk stratification. METHODS: One hundred fourteen patients underwent emergency open repair of RAAA. Data were retrospectively collected, and preoperative risk assessment was done according to the Glasgow aneurysm score, the Hardman index, and the Chen calculated risk. RESULTS: Fifty-one patients (44.7%) died during the immediate postoperative period. The area under the receiver operating characteristics curve for the Glasgow aneurysm score, the Hardman index, and the Chen calculated risk was 0.906, 0.834, and 0.672, respectively. The mortality rate among patients with a Glasgow aneurysm score >85 was 88.9%, whereas in those with a lower score it was 15.9% (P < .0001). The mortality rate among patients with a Hardman index > or =2 was 81.1%, whereas it was 27.3% in those with a lower score (P < .0001). The mortality rate in patients with a Chen calculated mortality risk >37% was 62.0%, whereas it was 31.3% in those with a calculated risk < or =37% (P = .001). CONCLUSIONS: The present study showed that the Glasgow aneurysm score and, to a somewhat lower extent, the Hardman score are valuable predictors of immediate postoperative death after emergency open repair of RAAA.     

Predictors for outcome after open and endovascular repair of ruptured abdominal aortic aneurysms.

OBJECTIVES: The aims of the present study were to analyze patient- and management-related predictors for outcome after open (OR) and endovascular repair (EVAR) of ruptured abdominal aortic aneurysm (rAAA). DESIGN: Retrospective study. MATERIALS: The in-hospital registry of Malm? University Hospital identified 162 patients operated on due to rAAA between 2000 and 2004. METHODS: Patient- and management-related predictors for outcome were analysed. RESULTS: Preoperative CT in 39 out of 62 circulatory unstable patients was not associated with increased mortality (p=0.60). There was a significant increase in repairs performed by EVAR during the study period (p<0.001), and in 2004 EVAR exceeded the annual rate of OR. Patients in the EVAR group were older (p=0.025), whereas patients in the OR group more often suffered from unconsciousness after presentation (p=0.004). Age, unconsciousness after presentation and haemoglobin were significantly associated with in-hospital mortality when tested in a multivariate logistic regression model (p=0.002, p=0.003 and p<0.001, respectively). The in-hospital mortality for patients undergoing OR and EVAR was 45% (48/106) and 34% (19/56), respectively (p=0.16). Diagnosis of abdominal compartment syndrome (p=0.005) and intestinal infarction (p=0.002) was associated with poor survival. CONCLUSIONS: Patient-related factors such as age, loss of consciousness and haemoglobin predicts outcome in a population where both emergency OR and EVAR for the treatment of rAAA is feasible.     

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.     

Quality of life after emergency abdominal aortic aneurysm repair.

BACKGROUND: Quality of life issues following surgical procedures, especially those with high mortality, should be of prime importance. There have been few studies on the quality of life of patients following emergency abdominal aortic aneurysm repairs. The decision to continue to offer surgery to these patients, especially with present monetary constraints, should rely heavily on quality of life issues. Audits of major surgical procedures should be undertaken and quality of life included. METHODS: All patients in the Hawkes Bay area who had undergone emergency abdominal aortic aneurysm repairs since 1981 were identified and their quality of life assessed by means of the short form-36 (SF-36) questionnaire. RESULTS: One hundred and fifteen patients were identified as having had an abdominal aortic aneurysm repaired as an emergency. Sixty patients died peri-operatively and 19 subsequently. There were 28 patients available to complete the questionnaire, of whom 75% rated their global quality of life as good to excellent. Using the SF-36 questionnaire, there was no statistically significant difference between those patients who had undergone surgery (whether proven leak or not) and the age-matched healthy population. CONCLUSIONS: Quality of life remains good to excellent in the majority of patients following emergency abdominal aortic aneurysm repairs. This may help justify surgery being offered to patients with this condition. Quality of life should be considered as an important outcome rather than mortality only.     

Clinical management of the symptomatic but unruptured abdominal aortic aneurysm

Pain or tenderness of an abdominal aortic aneurysm is widely believed to signify acute expansion and imminent rupture. To assess the potential benefit of emergency operation for the group of patients with an acutely expanding aneurysm, the clinical course of 19 patients with a symptomatic but unruptured expanding abdominal aortic aneurysm was compared with 117 patients undergoing elective abdominal aortic aneurysm resection, and 69 patients having operation for a ruptured abdominal aortic aneurysm. Postoperative morbidity was high in the patients with an expanding abdominal aortic aneurysm, and included a 21% incidence of myocardial infarction, a 10% incidence of stroke, a 37% risk of ventilatory failure, and a 31% incidence of acute renal failure, which was not statistically different from the results in patients having ruptured abdominal aortic aneurysm resection. Patients undergoing elective abdominal aortic aneurysm resection had only an 8% risk of myocardial infarction, and only a 2% risk of stroke, ventilatory failure, or renal failure. The mortality rate for expanding abdominal aortic aneurysm resection was 26% compared to 35% for ruptured abdominal aortic aneurysm (p = 0.31). Both emergency operations had a mortality rate more than five times greater than the 5.1% after elective procedures (p = 0.008). Our findings emphasize the need for early and aggressive treatment of abdominal aortic aneurysm in the elective setting, even in the patient at high risk, and suggest that the preoperative assessment and modification of risk factors is important to prevent the cardiac, cerebrovascular, pulmonary, and renal complications seen accompanying an emergency operation of this magnitude.     

Symptomatic seroma after open abdominal aortic aneurysm repair

Seroma following open abdominal aortic aneurysm repair has rarely been described. The majority of cases in the literature have been associated with use of polytetrafluoroethylene grafts. Here, we present a patient with a very large, symptomatic periaortic graft seroma 10 years after conventional (open) repair. The etiology of such seromas is of significant interest in endovascular aortic repair.     

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.