Ruptured abdominal aortic aneurysm.

A total of 131 surgically treated ruptured abdominal aortic aneurysms have been reviewed. Factors affecting morbidity and mortality rates have been analyzed. In our experience very little improvement has occurred in the last 10 years and the question is raised whether a plateau has been reached in the management of this catastrophic disease. Patient selection is not considered to be the key to better results, since some operated patients inevitably die. Improved technique with better, more rapid control of blood loss, especially from venous tears, will continue to yield better results. Eighty-six nonoperative cases have been studied. Diagnostic accuracy is lower than it should be, often leading to delayed surgery or death.     

Ruptured mycotic aortic aneurysm

A right flank mass, in a patient with fever of unknown origin, pain, and superiorly displaced right kidney on excretory urogram, was explored through a subcostal incision. Finding of a retroperitoneal abscess was anticipated; instead a ruptured mycotic aortic aneurysm was encountered. An awareness that entities such as this may exist is imperative in the differential diagnosis of flank masses. Treatment through a flank incision presents an elusive if not impossible feat. Because of the gravity of the underlying disease, misdiagnosis almost always results in death.     

Ruptured abdominal aortic aneurysm

Between 1974 and 1984, 174 patients with ruptured abdominal aneurysms have been treated by three vascular surgeons. The 11-year period showed a dramatic increase in the number of patients presenting with ruptured aneurysms. The overall operative survival, including patients who died before a graft could be inserted, was 67 per cent with improvement from 60 per cent in the first half of the period to 69 per cent in the second. The overall survival rate for the 162 who had a completed graft was 72 per cent. Reference to data from the Lothian area surgical audit showed that there has been a transfer of responsibility from general to vascular surgeons with an increase in the proportion of patients treated by operation. Concentration of care within a single specialized unit appears to have had a favourable effect on survival.     

Ruptured abdominal aortic aneurysm after endovascular aortic aneurysm repair

In treating uncomplicated abdominal aortic aenurysm, endovascular aortic aneurysm repair (EVAR) has been employed as a good alternative to open repair with low perioperative morbidity and mortality. However, the aneurysm can enlarge or rupture even after EVAR as a result of device failure, endoleak, or graft migration. We experienced two cases of aneurismal rupture after EVAR, which were successfully treated by surgical extra-anatomic bypass.     

Ruptured abdominal aortic aneurysm: the Harborview experience

During the last decade (1980 to 1989) 186 patients with ruptured abdominal aortic aneurysm were admitted to a single urban hospital. Ninety-six percent of these patients had a prehospital systolic blood pressure less than 90 mm Hg. Management included paramedic field resuscitation and transport, an emergency department diagnostic protocol completed in an average of 12 minutes, rapid transport to a dedicated emergency operating room, aneurysmorrhaphy by general surgery chief residents under the supervision of specialist vascular surgeons, and skilled postoperative intensive care unit care. Nevertheless, 130 (70%) patients died in the first 30 postoperative days--3% in the emergency department, 13% in the operating room, 51% in the intensive care unit, and 3% on the ward or at home. Certain features--age greater than 80 years, female gender, persistent preoperative hypotension despite aggressive crystalloid and blood replacement, admission hematocrit less than 25, transfusion requirements exceeding 15 units--were associated with a greater than 90% likelihood of death. No patient with preoperative cardiac arrest survived more than 24 hours. From this experience we conclude that, although "optimal" prehospital, emergency department, operating room, and postoperative care can improve the outcome of patients with ruptured abdominal aortic aneurysms in shock, most such patients will die. Certain clinical features predict such excessive mortality rates after ruptured abdominal aortic aneurysms that withholding operation may be reasonable. Screening of patients at high risk for abdominal aortic aneurysm, followed by elective aneurysmorrhaphy, is clearly indicated.     

Ruptured aortic aneurysm: a proposed classification

There is a wide variation in reported operative mortality rates for ruptured abdominal aortic aneurysm, ranging from 14 to 70 per cent. Although many factors influence this variation, such as the expertise and facilities available at an individual institution, considerable differences could be due to variations in the pattern of referral and the proportion of cases accepted for operation. In this paper a classification applicable to all patients with ruptured aortic aneurysm is proposed; it has been applied prospectively to 100 consecutive patients with ruptured abdominal aortic aneurysm referred to the Edinburgh Vascular Surgical Unit. The classification illustrates how surgical mortality rates ranging from 29 to 52 per cent may be reported using the same mortality data. Two major benefits may derive from the use of such a standard reporting system. Firstly, it allows management deficiencies to be identified easily and, secondly, it should facilitate comparison of results reported from different centres.     

Ruptured abdominal aortic aneurysm. The Tacoma experience

The Tacoma, Washington surgical experience with 37 consecutive patients with ruptured abdominal aortic aneurysms seen over a 5 year period has been reported. The overall survival rate was 38 percent. The development of shock before initiation of surgery was a common finding and portended a poor prognosis. The presence of a known aneurysm before presentation with rupture had no influence on the delay required to make the diagnosis and institute surgery or on the proportion of patients in shock but it did negatively influence the survival rate. The need for improved community understanding of aneurysms, their natural history, and the necessity for prompt diagnosis and immediate surgical intervention combined with avoidance of shock when rupture occurs are stressed.     

Ruptured abdominal aortic aneurysm: long-term survival]

Despite technological improvement, surgery for ruptured aortic abdominal aneurysm (AAA) only gets about 50% of patients to survive past the operative period. This series addresses the long-term outcome of those survivors. Eighty consecutive patients operated on for ruptured AAA between January 1983 and June 1990 at l'h?pital du Saint-Sacrement by three vascular surgeons, were studied and compared to 279 patients submitted to elective aneurysm surgery during the same period. The operative mortalities were respectively of 45% (ruptured) and 6.1% (elective). Five year survivals added up to 30 and 68%. When the 5 year survivals were recalculated, including only patients who were discharged from hospital, we found no statistically significant difference (p greater than 0.05) between the ruptured (55%) and the elective groups (68%). Data from this series demonstrate that long-term survival of patients undergoing ruptured AAA surgery is good and compares with that of AAA elective surgery. Therefore, aggressive treatment of ruptured AAA remains justified.     

Ruptured abdominal aortic aneurysm in the elderly patient

The authors discuss several aspects of the management of ruptured abdominal aortic aneurysm in elderly patients. The cost-effectiveness and indications of repair of rAAA in elderly patients are analysed. A literature survey of risk-factors and results of open treatment of rAAA in elderly patients is made. The challenge of endovascular repair of rAAA in the elderly patient is discussed. Finally, the authors report their personnal experience with AAA repair in 163 patients aged 75 years and older, operated on between January 2003 and September 2005(89 endoaneurysmal stentgrafts and 74 open repairs, 42 rAAA,23 symptomatic AAA and 98 selective asymptomatic AAA).     

Ruptured thoracoabdominal aortic aneurysm treatment in the United States: 1988 to 1998

OBJECTIVE: Thoracoabdominal aortic aneurysm (TAAA) rupture usually results in death. The outcome remains poor for patients who reach the operating room. The objective of this investigation was to define contemporary surgical experience with ruptured TAAA in the United States.Patients and methods Clinical data derived from the Nationwide Inpatient Sample on patients who underwent repair of a ruptured TAAA from 1988 to 1998 were analyzed. Age, sex, race, nature of admission, comorbid conditions, and provider volume were abstracted from the database. In-hospital mortality, postoperative complications, and length of stay were the principal outcome measures. RESULTS: Three hundred twenty-one patients were identified for the study. Mean age was 71.5 years; men outnumbered women (63% vs 37%). Crude overall surgical mortality was 53.8% and did not improve over time. Operative mortality was most likely (51%) to occur within the first 24 hours postoperatively. Median length of stay for surviving patients was 16 days. Renal failure (28%) and cardiac complications (18%) were the most common complications. In a logistic regression model, age greater than 77 years was predictive of death (odds ratio [OR], 2.5; P =.005), and nonwhite race appeared protective (OR, 0.53; P =.013). CONCLUSIONS: Mortality after surgical treatment of ruptured TAAA is high. Surviving patients experience many postoperative complications and have lengthy hospital stays. Given the lack of significant improvement in contemporary surgical practice, new techniques of repair deserve the attention of clinicians.     

Ruptured abdominal aortic aneurysm with horseshoe kidney

A case of ruptured abdominal aortic aneurysm associated with horseshoe kidney is presented. Two aspects of the operation are discussed: the vascular supply to the kidney and isthmus and the division of the isthmus. It is important in handling these cases either on an emergency basis or electively to be aware of the various vascular anomalies.     

Ruptured abdominal aortic aneurysm: Factors influencing operative mortality

Of fifty-eight consecutive patients surgically treated for aneurysm of the abdominal aorta, twenty were emergency cases following the rupture. Associated diseases were found in 85 per cent of patients; hypertension being the most common. Fifty per cent of patients were in shock on admission. The duration between rupture and operation was three hrs to two weeks with the average of 115.5 hrs. In six patients, the diagnosis of abdominal aortic aneurysm was known for over six months. The operative mortality rate in case of ruptured abdominal aortic aneurysm was 45 per cent. The most important determinants of survival were the incidence of shock on admission, the incidence of associated disease, the known duration of the aneurysm, and the time interval from rupture to admission. The intraoperative factors most influencing survival were the type of rupture, intraoperative hypotension, and total blood loss. Comparison of the mortality rate in elective surgery of abdominal aortic aneurysms (5.3 per cent) with that in ruptured aneurysms (45.0 per cent) suggests the necessity for early elective operations whenever abdominal aortic aneurysms are diagnosed. Presented at the Fifteenth Annual Meeting of the Japanese Association for Cardiovascular Surgery, Kanazawa, Japan, May 17–18, 1985.