Ruptured abdominal aortic aneurysm in a well-defined geographic area

OBJECTIVE: Despite an increasing number of elective operations on abdominal aortic aneurysms (AAAs), the age- and sex-standardized mortality rate of ruptured AAA (RAAA) continues to increase. In the Pirkanmaa region, population 440,000, all aortic surgery is performed at Tampere University Hospital (TAUH). Procedures have been collected into the vascular registry. The purpose of this study was (1) to establish the incidence, modes of treatment, and mortality of RAAA in a defined geographic area; (2) to evaluate the prerupture history to determine if there are any ways to prevent rupture; and to make a forecast about the increase of RAAAs in the next decades. METHODS: Population and outcome data in the Pirkanmaa region and information on all patients who died of RAAA during 1990-1997 were provided by Statistics Finland. All operated RAAAs that underwent procedures during 1990 to 1999 were identified from the local vascular registry. To make a forecast for the next decades, an incidence of RAAA was calculated separately for each age group in 5-year intervals. RESULTS: From 1990 to 1997, 221 patients presented with RAAA. The mean incidence was 6.3/100,000 inhabitants. The incidence in the population over 65 years was 35.5/100,000. The total RAAA mortality was 76.9%. A total of 139 patients reached TAUH and 111 underwent emergency surgery. The overall hospital mortality in TAUH was 63.3%. The calculated annual number of RAAA will increase 49.6% in the next 2 decades, and the overall incidence will increase from 6.3 to 8.9/100,000 inhabitants. According to the vascular registry, 166 patients were operated on for RAAA during 1990 to 1999 in TAUH. The 30-day mortality was 50.6%. A minority of the patients (n = 18, 10.8%) had a previously documented AAA. The median diameter at the time of rupture was 7 cm. Seven (5.0%) men and six (24.0%) women had a diameter of less than 5.5 cm. CONCLUSION: The incidence of RAAA in the Pirkanmaa region in 1990s was the Finnish average. In the next two decades, the number of individuals with RAAA will increase significantly. One quarter of women had a diameter of AAA at the time of rupture that was under the current threshold indicator for elective operation.     

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

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

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

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

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

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

Ruptured versus Elective Abdominal Aortic Aneurysm Repair: Outcome and Cost

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

Long-term survival and late complications after repair of ruptured abdominal aortic aneurysms

Purpose:Long-term survival and late vascular complications in patients who survived repair of ruptured abdominal aortic aneurysms (RAAA) is not well known. The current study compared late outcome after repair of RAAA with those observed in patients who survived elective repair of abdominal aortic aneurysms (AAA). Methods:The records of 116 patients, 102 men and 14 women (mean age: 72.5 (8.3 years), who survived repair of RAAA (group I) between 1980 to 1989 were reviewed. Late vascular complications and survival were compared with an equal number of survivors of elective AAA repair matched for sex, age, surgeon, and date of operation (group II). Survival was also compared with the age and sex-matched white population of west-north central United States. Results:Late vascular complications occurred in 17% (20/116) of patients in group I and in 8% (9/116) in group II. Paraanastomotic aneurysms occurred more frequently in group I than in group II (17 vs. 8,p = 0.004). At follow-up, 32 patients (28%) were alive in group I (median survival: 9.4 years) and 53 patients (46%) were alive in group II (median survival: 8.7 years). Cumulative survival rates after successful RAAA repair at 1, 5, and 10 years were 86%, 64%, and 33%, respectively. These were significantly lower than survival rates at the same intervals after elective repair (97%, 74%, and 43%, respectively, p = 0.02) or survival of the general population (95%, 75%, and 52%, respectively,p < 0.001). Coronary artery disease was the most frequent cause of late death in both groups. Vascular and graft-related complications caused death in 3% (3/116) in group I and 1% (1/116) in group II. Cox proportional hazards modeling identified age p = 0.0001), cerebrovascular disease p = 0.009), and number of days on mechanical ventilation p = 0.01) to be independent prognostic determinants of late survival in group I. Conclusions:Late vascular complications after repair of RAAA were higher and late survival rates lower than after elective repair. These data support elective repair of AAA. As two-thirds of the patients discharged after repair of RAAA are alive at 5 years, aggressive management of RAAA remains justified. (J Vasc Surg 1998;27:813-20.)     

A review of 102 consecutive patients with intracranial aneurysms in a community hospital in Japan

Summary One hundred and two consecutive non selected patients with intracranial aneurysms were reviewed. The incidence of ruptured aneurysm was 17.5 per population of 100,000 per year. The patients were divided into two groups, according to a change of policy that reversed the timing of operations from delayed to early surgery. The overall mortality and occurrence rate of neurological deficits due to vasospasm in patients in Hunt and Kosnik grades I through III were found to be lower during the period with a policy of early surgery. Elderly patients over 70 years old constituted 19% of the cases and those in poor condition (grade IV and V) 31%. These figures in this study are high, which may reflect the fact that these are common problems inherent in the treatment of ruptured aneurysms without patient selection at most community hospitals in the forefront of primary medical care.     

Survival of ruptured abdominal aortic aneurysms in the west of Ireland: do prognostic indicators of outcome exist?

Ruptured abdominal aortic aneurysm (RAAA) is a demanding vascular surgical problem and the cause of significant morbidity and mortality. The aim of this study was to identify prognostic factors that influence outcome. Over 6 years, 42 ruptured abdominal aortic aneurysms were operated on with a mean diameter of 7.2 cm. RAAA was defined as free intraperitoneal rupture. Data were collected retrospectively from hospital medical records. The male: female ratio was 8:1 and the mean age was 74 years (range 55-89). Fifteen were in hypovolemic shock and 27 patients were clinically stable. The perioperative mortality rate for the 15 shocked patients was 60% (9 patients) and the 1-year cumulative survival rate was 33%. The perioperative mortality rate for the 27 clinically stable patients was 40% (11 patients) and the 1-year cumulative survival rate was 56%. Survival curves were constructed for these groups to compare male versus female, age >/= 70 versus age < 70, shocked versus stable, and preoperative hemoglobin (Hb) 10. No patient with preoperative cardiac arrest survived more than 24 hours. With VassarStats, the confidence interval for age, gender, hemodynamic status, and preoperative Hb were calculated. The standard weighted mean analysis by ANOVA gave a p value of < 0.001. The overall 30-day mortality rate was 47% (20 of 42) and the 1-year mortality rate was 52% (22 of 42). Male patients over 70 years with RAAA in hypovolemic shock with low Hb have a higher 30-day mortality rate and few survive more than 1 year. The study suggests that each of these 4 parameters separately was not a strong prognostic indicator. Collectively, however, they strongly influence the prognosis of patients with RAAA. These findings strengthen the case for selective treatment for RAAA.     

Epidemiology and Outcome of Aortic Aneurysms in Hong Kong

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

Impact of vascular surgery on community mortality from ruptured aortic aneurysms

The workload of aortic surgery in a district increased fourfold over 10 years as the incidence of aneurysm rupture rose from 7 to 17/100,000. Of 260 patients with ruptured aneurysms 101 reached hospital alive (38 per cent) of which 52 (52 per cent) survived, an overall survival rate of 19.8 per cent. Despite increasing experience, mortality after emergency surgery did not improve, suggesting outcome was largely determined by the patient's condition and age. Only 5 of 90 patients aged over 75 survived aortic rupture at home. In consequence overall community mortality did not improve in the period studied. Survival after elective surgery was 95 per cent, suggesting that efforts to improve survival should be directed towards identifying and treating the disease before rupture occurs. The commonly stated figure of 50 per cent survival for ruptured aortic aneurysms is an overestimate, due to neglect of patients dying at home.     

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

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

Elective aneurysm repair and the incidence of aortic rupture in an ageing population

During the period January 1984-July 1988, 191 abdominal aortic aneurysms were encountered at Gosford District Hospital, NSW, a hospital that services an ageing population. These aneurysms were either repaired or found as the cause of death at post-mortem. During the study, the rate of elective repair rose from 0.25/month during the first 2 years to 3.67/month in the latter 2.5 years. The mortality for repair of non-ruptured aneurysms was 0.9% compared with 55% for ruptured aneurysms. The 15-fold increase in elective repair resulted in the 58% reduction in the incidence of abdominal aortic rupture from 1.87/month to 0.79/month. The mortality rate from known aneurysms fell from 46% to 14% in the final 2 years. Elective aneurysm repair reduces the incidence of and death from abdominal aortic rupture in an ageing population.     

Quality of life and long-term results after ruptured abdominal aortic aneurysm.

OBJECTIVES: Quality of life as an endpoint of surgery and the long-term prognosis for patients who have survived surgery for a ruptured abdominal aortic aneurysm (RAAA) is not well-documented. PATIENTS AND METHODS: The records of all patients from 1993 to 2000 who underwent resection of RAAA were reviewed. Survival data were calculated from direct contact with the patients or follow-up records. All patients who were alive at the time of our study were invited to participate in follow-up investigations. They received the internationally comparable WHO-QOL-BREF-test. RESULTS: In a period of 7 years, 80 patients underwent surgery for RAAA. The average follow-up time was 5.1 years (1-7.9 years). Our data show that 51% of our patients died within 6 months postoperatively because of the complications of the aortic rupture (in-hospital mortality 39%). Patients who survived the first 6 months after surgery died for the same reasons as the normal population. However, patients who were younger than 75 at the time of RAAA had a higher relative survival rate than a matched sample of the population. There was no significant difference in the quality of life between the study group and the general population. CONCLUSIONS: RAAA survivors had no difference in long-term survival as compared to the general population and also had very few long-term complications. The WHOQOL-BREF-test suggests that the quality of life of survivors of RAAA is similar to the general population.     

Aneurysm of the thoracic aorta. Review of 260 cases

In a 1980 review of the natural history and treatment of 176 thoracic aortic aneurysms, we noted the high incidence of rupture (47% overall) in 135 patients not treated surgically. Since that original study we have added another 84 patients to our series and have noted a complete change in management such that most patients are now treated surgically. We now have 260 patients in our series, 126 of whom were treated surgically. Sixty-seven were emergency operations and 59 were elective. Surgical mortality was 8% for elective resection and 33% for emergency operation. Over the past 5 years these figures have improved to 5% surgical mortality for elective resection and 16% surgical mortality for emergency resection. The 5 year survival rates for the entire series were 50% for patients treated with elective operation, 30% for combined emergency and elective operation groups, and 21% for nonsurgically treated patients. Abdominal aortic aneurysm was present in 74 patients (28%) and 23 of these patients had undergone a prior resection of an abdominal aortic aneurysm. This series documents the improved survival of patients with aneurysms of the thoracic aorta who are treated with prompt surgical intervention. It also further substantiates earlier findings of a high incidence of aneurysms of the abdominal aorta in this patient population.     

Abdominal aortic aneurysms: the changing natural history

The records of all patients with abdominal aortic aneurysms (AAAs) in a Midwest city with a stable population over a 30-year period were reviewed. There were 296 patients (196 men and 100 women) for an incidence of 21.1 aneurysms/100,000 person-years. The median age at diagnosis was 69 years for men and 78 years for women. Seventy-eight percent of patients were asymptomatic at the time of diagnosis; their aneurysms were incidental findings. Rupture occurred in 60 patients (20.3%). Thirty-six patients (12.2%) had rupture of the aneurysm as the presenting complication. For previously diagnosed aneurysms that subsequently ruptured, the average period from diagnosis to rupture was 48.7 months. Rupture occurred in only two aneurysms smaller than 5 cm. The overall mortality rate from rupture was 15.5%. Evaluation of data (including autopsy reports) by decade revealed an absolute increase in the incidence of AAAs in the population under study. More aneurysms of all sizes occurred from 1971 to 1980 than in the previous two decades combined. Although ultrasound examination has increased the detection of small aneurysms, the incidence of aneurysms 7 cm or larger at the time of diagnosis has also increased; the frequency of rupture was greatest in the last decade. To compare the data of the population-based study with the statistics for patients seen in a referral practice, the records of 616 patients from a referral population were also reviewed. In the referral population the ratio of men to women was 5:1, and the age at diagnosis was lower for both groups.(ABSTRACT TRUNCATED AT 250 WORDS)     

腹主动脉瘤破裂的处理及预后分析

目的探讨腹主动脉瘤破裂的处理及影响预后的主要因素。方法回顾性分析12年间收治的42例腹主动脉瘤破裂的临床资料。85．7％的患者术前行影像学检查确诊。36例行手术治疗,其中35例行腹主动脉瘤切除人工血管植入术,术中80％采用肾动脉下腹主动脉阻断, 14．3％采用膈下腹主动脉阻断,5．7％采用Foley尿管球囊阻断（2例）;1例行覆膜支架腔内隔绝术。结果围手术期死亡率45．24％。单因素统计分析表明在围手术期死亡者年龄（72．1±1．0）岁、合并疾病13例和术前收缩压（82±53）mm Hg;存活者年龄（61．5±17．0）岁、合并症7例、术前收缩压（82±28）mm Hg,之间差异有统计学意义（P〈0．05）,而性别、术前Hb、肌酐、瘤体直径和手术失血量则无显著差异（P〉0．05）。结论手术是治疗破裂腹主动脉瘤的惟一有效方法,高龄、合并其他疾病和休克提示预后不良。     

Outcomes of endovascular treatment of ruptured abdominal aortic aneurysms

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

Endovascular repair of ruptured abdominal aortic aneurysms: a systematic review and meta-analysis

OBJECTIVES: The perioperative mortality for people with ruptured abdominal aortic aneurysms (RAAA) has not changed for two decades. Of patients who survive long enough to undergo open repair for ruptured aneurysms, half die (48%; 95% confidence interval [CI] 46 to 50). Randomized trials have shown that endovascular aneurysm repair (EVAR) for nonruptured abdominal aortic aneurysms decreases perioperative mortality compared with open repair. EVAR may similarly benefit patients with RAAA. We aimed to summarize studies of patients undergoing EVAR for ruptured aneurysms. METHODS: Two reviewers searched Medline and EMBASE databases from 1994 to July 2006, Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effectiveness, the Cochrane Central Register of Controlled Trials, Best Evidence 1994 to 2006, reference lists, clinical trial registries, and conference proceedings; we also contacted authors. All published and unpublished studies in which a group of people with ruptured aneurysms, assessed objectively by imaging, was treated with EVAR (REVAR) were eligible. We used the generic inverse variance function of the REVMAN software to pool results for death in hospital. Sensitivity analyses, using prespecified subgroups, explored heterogeneity between studies. RESULTS: Pooled mortality in 18 observational studies describing 436 people who underwent REVAR was 21% (95% CI 13 to 29); however, 90% of the heterogeneity between studies was not explained by chance alone. Surgical volume explained substantial heterogeneity. According to study-specific criteria, 47% (95% CI 39 to 55) of people with ruptured aneurysms were potentially eligible for REVAR. CONCLUSIONS: Mortality in people who underwent REVAR is lower than that in historical reports of unselected people undergoing open repair. Further investigation is needed to determine whether the difference in mortality is attributable to patient selection alone or to this new approach to treatment.     

Outcomes of surgical management of ruptured abdominal aortic aneurysm

Background Ruptured abdominal aortic aneurysms have remained a challenge to the cardiovascular surgeon. They are rapidly fatal if left untreated with reported mortality rates approaching 50%. Urgent surgery is the accepted modality of therapy. We report the outcome of surgical management of this subset of patients. Methods We retrospectively analyzed case records of 36 consecutive patients who underwent surgery for ruptured infra-renal abdominal aortic aneurysm (RAAA) at our institute between January 1990 and January 2005. Thoraco-abdominal & iliac aneurysms were excluded from the study. Mean age was 59 years±14.3 (Range—20 to 81 years). 33 of the patients were operated as an emergency. Systemic hypertension, renal dysfunction and coronary artery disease were the major co-morbid conditions. Results Hospital mortality was 42% (15/36 patients). 6 patients died of diffuse bleeding and coagulopathy, 5 patients had peri-operative myocardial infarction, 2 patients developed acute renal failure, and 1 each died of large bowel gangrene and massive haemoptysis. Follow up ranged from 2 to 9 years with a mean of 4.3 years. There were no major morbidities at mid-term follow-up. Conclusion Emergency surgery for RAAA continues to be associated with a high mortality rate, despite the improvements in surgical techniques and post-operative care. Early detection and subsequent treatment would circumvent the high mortality associated with these patients.     

Lifetime gain related to cost of repair of ruptured abdominal aortic aneurysm in octogenarians.

OBJECTIVE: To report cost related to gained life years after repair of ruptured abdominal aortic aneurysms in patients aged 80 or older. DESIGN: A retrospective study based on prospectively registered data. PATIENTS AND METHODS: Fifty-three patients aged 80 or older were operated on for ruptured abdominal aortic aneurysm over a 20-year period from 1983 to 2002. Thirty-one (58%) patients had systolic BT <80 mmHg. Operative mortality (<30 days) and long-term survival were studied. The number of life-years gained from the operations was estimated. Based on diagnose related group (DRG) values, the cost of each gained life-year was calculated. RESULTS: The operative mortality was 47%. Long-term survival of those patients who survived the operation was similar to that of an age and sex matched population. The 53 operations resulted in 145 gained life-years, which leaves a mean survival of 2.7 years of all the patients and 5.2 years of those who survived the operation. The estimated cost per gained life year was euro6817. CONCLUSIONS: The operative mortality of ruptured abdominal aortic aneurysm remains high. The long-term survival of patients who survive the operation is acceptable. The price of each gained life-year is low, as compared to other established treatment modalities. Improved results with endovascular treatment may even decrease the cost per gained life year.