Mortality,Morbidity, and Costs of Ruptured and Elective Abdominal Aortic Aneurysm Repairs in Nova Scotia,Canada

Ruptured abdominal aortic aneurysms (RAAA) have a 78-94% mortality rate. If cost-effectiveness of screening programs for abdominal aortic aneurysms (AAA) are to be assessed, direct costs for RAAA repairs and elective AAA (EAAA) repairs are required. This study reports mortality, morbidity, and direct costs for RAAA and EAAA repairs in Nova Scotia in 1997-1998 and also compares Nova Scotia and U.S. costs. We performed a retrospective study of 41 consecutive RAAA and 48 randomly selected EAAA patients. Average total costs for RAAA repair were significantly greater than those for EAAA repair (direct costs: $15,854 vs. $9673; direct plus overhead costs: $18,899 vs. $12,324 [pricing in 1998 Canadian dollars]). Intensive care unit length of stay and blood product usage were the most substantial direct cost differentials ($3593 and $2106). Direct cost for preoperative testing and surveillance was greater in the EAAA group ($839 vs. $33). Estimates of U.S. in-hospital RAAA and EAAA repair costs are more than 1.5 times Nova Scotia costs. Direct in-hospital RAAA repair costs are $6181 more than EAAA repair costs. These in-hospital cost data are key cost elements required to assess the cost-effectiveness of various screening strategies for earlier detection and monitoring of AAA within high-risk populations in Canada. Further studies are required to estimate cost per quality-adjusted-life-year gained for various AAA screening and monitoring strategies in Canada.     

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.     

Health-related quality of life in survivors of open ruptured abdominal aortic aneurysm repair: a matched, controlled cohort study

OBJECTIVE: The objective of this study was to document the health-related quality of life (HRQOL) for patients who survived operative repair of a ruptured abdominal aortic aneurysm (RAAA) and to compare this with a matched group of patients who survived elective operative repair of an abdominal aortic aneurysm (EAAA). METHODS: A matched, controlled cohort study of HRQOL was used to compare patients surviving RAAA with an EAAA control group. The study was conducted at two university-affiliated vascular tertiary care referral centers. Survivors of RAAA and EAAA during an 8.5-year period were identified and followed up. The RAAA and EAAA control patients were matched for age, serum creatinine concentration, gender, and duration of follow-up since surgery. HRQOL was measured with the Medical Outcomes Study Short Form-36 Health Survey (SF-36). Scores for the EAAA and RAAA cohorts were also compared with age-corrected SF-36 population scores. RESULTS: Of 267 patients operated for RAAA during the study period, 130 (49%) survived to hospital discharge. Death after discharge was documented in 35 patients, leaving a potential study population of 95 RAAA survivors. Thirteen were lost to follow-up, seven refused to participate, and four patients were not able to participate. The SF-36 was completed by 71 RAAA patients (75% of surviving RAAA patients). The 71 RAAA survivors and 189 EAAA control patients were similar for seven of eight domains of the SF-36: Physical Function, Role-Physical, Bodily Pain, General Health, Vitality, Mental Health, and Role-Emotional. There was also no difference in the Physical Health Summary and Mental Health Summary scores. The social function component of the SF-36 demonstrated a statistically significant decline in the EAAA group. Both the EAAA and RAAA SF-36 individual and summary scores compared favorably with population norms that were adjusted only for age. CONCLUSION: Long-term survivors of RAAA enjoy a HRQOL that does not differ significantly from EAAA survivors. Scores for both groups compare favorably with population scores adjusted only for age.     

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.)     

Outcome in patients requiring renal replacement therapy after surgery for ruptured and non-ruptured aneurysm of the abdominal aorta.

OBJECTIVES: to study the course of postoperative acute renal failure requiring renal replacement therapy (RRT) in patients with ruptured (RAAA) and non-ruptured (EAAA) aneurysm of the abdominal aorta (AAA) and to investigate the predictive value regarding outcome of parameters collected during the illness. DESIGN: retrospective study in a university hospital. MATERIALS AND METHODS: the records of 42 patients, 21 with RAAA and 21 with EAAA, were reviewed. RESULTS: overall mortality was 69%, 71% for RAAA patients and 66% for EAAA patients. RRT was started 9 (2-28) days - median (range) - postoperatively and continued during 9 (2-50) days. Renal function recovered in nine of the 13 survivors after 18 (2-50) days. Length of ICU stay was 50 (2-132) days for survivors vs. 19 (6-56) days for non-survivors. The systemic inflammatory response syndrome (SIRS) or need for vasoactive support was associated with poor outcome and the ability to wean from vasoactive or ventilatory support with improved outcome. CONCLUSIONS: RAAA and EAAA patients requiring postoperative RRT both had a high mortality. The ICU stay of non-survivors was shorter than that of survivors, who had a 75% chance of regaining renal function. The ability to wean from ventilatory and inotropic support may be of help in the clinical management of patients requiring RRT after AAA surgery.     

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.     

The true incidence of ruptured abdominal aortic aneurysms

The number of ruptured abdominal aortic aneurysms (RAAA) was documented over an 8-year-period in a known population age group. Patient figures were collected from the operative and post-mortem registers in the Worthing Health District. The overall mean incidence of RAAA was 13.9/100,000 patient years, although the incidence was noted to increase from 9.2 to 17.5/100,000 patient years during this period. The incidence in the male population rose from 4.7/100,000 for those in the fifth decade to 184.8/100,000 for those above 80. For patients undergoing operation, the peri-operative survival was 38%, however the overall survival was 11% as 64% of patients died at home. These figures demonstrate an increasing incidence of ruptured AAA. They also add support to the need for screening of asymptomatic abdominal aortic aneurysms and elective repair if the incidence and hence mortality is to be reduced.     

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.     

Rupture of abdominal aortic aneurysm (RAAA)--predictors of the early postoperative mortality

PURPOSE: To evaluate the main factors of the 30 days mortality rate of patients operated on for abdominal aortic aneurysm rupture (RAAA. PATIENTS AND METHOD: Univariate and multivariate analysis of various factors associated with RAAA was performed in a group of 73 patients operated on for RAAA between 1996-2001. RESULTS: The 30 days mortality rate was 35.6 %. The main factors of mortality were: misdiagnosis, cardio- pulmonary-cerebral resuscitation (CPCR) on admission, configuration of RAAA, number of blood transfusions, hypotension on admission (p < 0.0001) and duration of operation, type of reconstruction and hypertension in anamnesis (p < 0.01). Important factors (p < 0.05) of postoperative mortality were also low haemoglobin level on admission, abdominal aortic aneurysm (AAA) diameter and ischaemic heart disease in anamnesis. The probability of patient's death is the highest (p < 0.003), if factors like CPCR, number of blood transfusions and aneurysm diameter are combined (multivariate analysis, stepwise method). CONCLUSION: The early detection and surgical or endovascular elective treatment of AAA, the regular dispensation of patients with small AAA especially in hypertonics, the correct diagnosis of RAAA without time delay are the best tools for patients survival. The patient's chance for survival increases with highly trained prehospital resuscitation system and experienced team of vascular surgeons and anesthesiologists.     

Outcome after Simultaneous Abdominal Aortic Aneurysm Repair and Aortocoronary Bypass

Myocardial infarction remains the leading cause of early and late death after abdominal aortic aneurysm (AAA) repair. Myocardial revascularization is staged either before or concomitant with AAA resection, but results are far from uniform. We retrospectively analyzed our experience with patients who underwent concomitant AAA resection and aortocoronary bypass (ACB) to examine the factors affecting early morbidity/mortality and early results. Forty-two patients (all men; mean age, 67.2 years) underwent simultaneous ACB grafting and AAA repair between 1975 and 1998. All were managed postoperatively in the cardiothoracic intensive care unit (mean stay, 6.1 days). The mean total hospital stay was 17.2 days. Two died in the early postoperative period (4.8%): 1 of sustained myocardial failure following a third ACB, and 1 of coagulopathy after concomitant ACB, aortic valve replacement, and AAA. One patient developed a nonfatal MI on postoperative day 3. The incidence of wound and bleeding complications was higher for patients undergoing both ACB and AAA repair than for patients undergoing AAA resection alone. On follow-up (mean, 10 years; range, 7 months to 15 years), only 2 of 10 late deaths were due to cardiovascular causes. We believe that concomitant myocardial revascularization is warranted in select patients requiring elective or urgent AAA resection in order to decrease perioperative risk and improve late survival. Cardiac failure or ischemia during aortic surgery can be prevented by proper perfusion with or without cardiopulmonary bypass. In patients undergoing simultaneous procedures, the increased risk is related to the severity of the vascular and coronary artery disease and not to the combined operations.     

Endovascular abdominal aortic aneurysm repair with general versus local anesthesia: a comparison of cardiopulmonary morbidity and mortality rates

PURPOSE: The purpose of this study was to compare the cardiopulmonary morbidity and mortality rates after endovascular abdominal aortic aneurysm (EAAA) repair with local anesthesia (LA) with intravenous sedation versus general anesthesia (GA). METHODS: Data from patients who underwent elective infrarenal EAAA repair between June 1996 and October 2000 were retrospectively reviewed. Patients with two or more Eagle clinical cardiac risk factors were considered to be at increased risk for a major postoperative cardiac event. Univariate and multivariate analyses for major cardiac and pulmonary morbidity and mortality rates were analyzed with respect to anesthetic type (GA versus LA), age, size of aneurysm, mean number of Eagle risk factors, and presence of two or more cardiac risk factors. RESULTS: Two hundred twenty-nine patients underwent EAAA repair. The GA (158 patients) and LA (71 patients) groups were significantly different with respect to mean age (73 versus 76 years; P =.01) and mean number of cardiac risk factors per patient (1.2 versus 1.6; P =.002). No difference was seen in the overall cardiopulmonary complication rate (13% for GA and 19% for LA; P =.3), pulmonary complication rate (3.8% for GA and 7% for LA; P =.3), or cardiopulmonary mortality rate (3.2% for GA and 2.8% for LA; P =.9). The major cardiac event rate was higher in patients with two or more Eagle risk factors (22%) versus those patients with one or less Eagle risk factors (3.4%; P <.001), irrespective of anesthetic type. In analysis of patients with one or less Eagle risk factors, no difference was seen in the major cardiac event rate by anesthetic type (3% for GA and 5% for LA; P =.6). Also, no difference was seen in major cardiac events in patients with two or more Eagle risk factors by anesthetic type (24% for GA and 22% for LA). On multivariate analysis, the mean number of Eagle risk factors per patient (P <.0001) and the presence of two or more Eagle risk factors were associated with major cardiac and cardiopulmonary complications, whereas age, size of AAA, and anesthetic type were not. CONCLUSION: No difference exists in overall cardiac and pulmonary morbidity and mortality rates after EAAA repair in comparison of GA and LA. The presence of two or more preoperative cardiac risk factors significantly increases the risk of a major postoperative cardiac event.     

Current results of elective aortic reconstruction for aneurysmal and occlusive disease

Decisions to resect small aortic aneurysms or employ non-operative treatment for aorto-iliac occlusive disease must depend on current rather than historical surgical results. To assess current morbidity and mortality, we reviewed 200 consecutive aortic resections in two groups of patients treated from 1981 to 1989: those undergoing elective aortofemoral bypass for occlusive disease (AFB, no. 100) or resection of infrarenal abdominal aortic aneurysms (AAA, no. 100). Indications for AFB included claudication (54%), rest pain (32%), and gangrene (13%). AAA size ranged from 3 to 14 cm (mean 6.5 +/- 2.4 cm); 45% presented with abdominal or back pain. Patients undergoing AFB were younger (AFB 61.5 +/- 10 years vs AAA 68.7 +/- 8.9 years) with a higher incidence of some atherosclerotic risk factors, diabetes mellitus 30% vs 10%, tobacco use 77% vs 49%, hyperlipidemia 21% vs 7%; p less than 0.001). Coronary artery disease (CAD) was more prevalent in AAA patients (49% vs 34%; p less than 0.001). Postoperative mortality was not different in occlusive or aneurysmal disease (3% AFB vs 2% AAA), nor was the occurrence of serious complications such as myocardial infarction (2% vs 1%) or pulmonary embolism (2% vs 3%). Improvements in patient selection, perioperative care and surgical technique have lowered the mortality of elective aortic surgery. Given the current standard of care, an aggressive approach to AAA even in high risk patients is appropriate. The low morbidity of AFB for occlusive disease mandates a critical appraisal of less effective nonoperative therapies.     

Intestinal ischemia following replacement of the infrarenal aorta and aorto-iliac bifurcation]

Intestinal ischemia following abdominal aortic surgery is a rare but dreaded complication and is associated with a high postoperative morbidity and mortality. Based on a review of the literature the incidence was noted between 2% to 10% of patients undergoing reconstruction of the abdominal aorta. From January 1980 to March 1991, 1017 patients were operated on the abdominal aorta or aorto-iliac bifurcation; the diagnosis was either abdominal aortic aneurysm (AAA) or chronic occlusive disease (COD). There were 819 patients with AAA (80.5%, mean age 67.9 years), and 198 patients with COD (19.5%, mean age 62.2 years). In 134 cases (122 for AAA, 12 for COD) the inferior mesenteric artery (IMA) was reimplantated into the graft. The incidence of postoperative intestinal ischemia after AAA repair was 2.8% (23/819 patients) after AAA repair and 0.5% (1/198 patient) with COD. 66% of the patients who have developed intestinal ischemia were operated emergently. However 2/134 (1.5%) patients presented intestinal ischemia despite reimplantation of IMA. Early explorative laparotomy or early postoperative colonoscopy could demonstrate ischemia in the majority of cases, whereas diagnosis of intestinal ischemia was confirmed at autopsy in 2 patients. In our experience with more than 1000 patients operated on the infrarenal aorta during a 10-year period suggests that a postoperative intestinal ischemia is caused mainly by a misbalance of the blood supply of the left hemicolon and rectosigmoid and may be prevent by reimplantation of IMA. Our actual policy consider reimplantation in presence of patent and large IMA with weak backflow, especially in patients with previous colonic disease or by missing collaterals at preoperative angiogram.     

Contemporary results of open repair of ruptured abdominal aortoiliac aneurysms: effect of surgeon volume on mortality

OBJECTIVE: The purpose of this study is to evaluate contemporary results of ruptured aortoiliac aneurysms (RAAA) and identify the role of surgeons' annual aortic volume and other prognostic indicators for early outcome. METHODS: A retrospective review identified 213 consecutive patients who presented with an atherosclerotic RAAA without thoracic extension over 6.5 years ending in June 2007. Excluded were 31 ruptures treated by endovascular repair (EVAR) or following previous EVAR, also excluded were two chronic asymptomatic hemodynamically stable ruptures. Ten patients were not treated due to either patient's refusal or prohibitive surgical risk. Demographic, preoperative, intraoperative, and postoperative variables were collected. Log rank test and Cox proportional hazard model analyses were utilized to identify factors contributing to mortality and morbidity in these patients. Survival rates were estimated by Kaplan-Meier method. RESULTS: One hundred thirty-one males and 39 females with a mean age of 74.5 +/- 8.1 years underwent consecutive RAAA repairs. The operative mortality rate was 38.2% (65/170), including 29 intraoperative deaths. Using multivariate analysis, surgeon's average annual AAA volume (<20/y), advanced age, and postoperative intestinal ischemia were independent predictors of perioperative deaths. Shock on presentation, preoperative cardiopulmonary resuscitation or free rupture were not. High-volume surgeons (>20 average annual AAA cases/y) had a higher 30-day survival rates (78.4% vs 57.9%, P = .024). Octogenarians had a lower 30-day survival rate of 49.0% vs 70.5% (P = .012). Patients who developed postoperative intestinal ischemia had a lower 30-day survival rate compared with patients without (48.1% vs 15.3%, P = .002). Increased intraoperative fluid and blood product usage was associated with bowel ischemia (P < .05). CONCLUSIONS: RAAA remains a highly lethal problem. The improved early outcomes of surgeons with high-volume AAA have strong implications for training, emergency staffing needs and alternative treatment strategies.     

Early inflammatory response after elective abdominal aortic aneurysm repair: a comparison between endovascular procedure and conventional surgery

OBJECTIVE: To determine the nature of and to compare the inflammatory responses induced by (1) endovascular and (2) conventional abdominal aortic aneurysm (AAA) repair.Material and Methods: Twelve consecutive patients undergoing elective infrarenal AAA repair were prospectively studied. Seven patients were selected for endovascular procedures (the EAAA group); five patients underwent open surgery (the OAAA group). Three control patients undergoing carotid thromboendarterectomy were also included. Serial peripheral venous blood samples were collected preoperatively, immediately after declamping or placement of the endograft, and at hours 1, 3, 6, 12, 24, 48, and 72. Acute phase response expression of peripheral T lymphocyte and monocyte activation markers and adhesion molecules (flow cytometry), soluble levels of cell adhesion molecules (enzyme-linked immunosorbent assay), cytokine (tumor necrosis factor alpha, interleukin-6, and interleukin-8) release (enzyme-linked immunosorbent assay), and liberation of complement products (nephelometry) were measured. RESULTS: Regarding acute phase response, the EAAA and OAAA groups showed significant increases in C-reactive protein (P <.001 and P =.001), body temperature (P =.035 and P =.048), and leukocyte count (P <.001 and P <.001). Similar time course patterns were observed with respect to body temperature (P =.372). Statistically significant different patterns were demonstrated for C-reactive protein (P =.032) and leukocyte count (P =.002). Regarding leukocyte activation, a significant upregulation of peripheral T lymphocyte CD38 expression was observed in the OAAA group only (P =.001). Analysis of markers such as CD69, CD40L, CD25, and CD54 revealed no perioperative fluctuations in any group. Regarding circulating cell adhesion molecules, the EAAA and OAAA groups displayed significant increases in soluble intercellular adhesion molecule-1 (P =.003 and P =.001); there was no intergroup difference (P =.193). All groups demonstrated high soluble von Willebrand factor levels (P =.018, P =. 007, and P =.027), there being no differences in the patterns (P =. 772). Otherwise, soluble vascular cell adhesion molecule-1, soluble E-selectin, and soluble P-selectin did not appear to vary in any group. Regarding cytokine release, although a tendency toward high tumor necrosis factor alpha and interleukin-8 levels was noticed in the EAAA group, global time course effects failed to reach statistical significance (P =.543 and P =.080). In contrast, interleukin-6 showed elevations in all groups (P =.058, P <.001, and P =.004). Time course patterns did not differ between the EAAA and OAAA groups (P =.840). Regarding complement activation, the C3d/C3 ratio disclosed significant postoperative elevations in the EAAA and OAAA groups (P =.013 and P =.009). This complement product release was reduced in the EAAA group (P <.001). CONCLUSIONS: The current study indicated that both endovascular and coventional AAA repair induced significant inflammatory responses. Our findings showed that there were no large differences between the procedures with respect to circulating cell adhesion molecule and cytokine release. Moreover, the endoluminal approach produced a limited response in terms of acute phase reaction, T lymphocyte activation, and complement product liberation. This might support the concept that endovascular AAA repair represents an attractive alternative to open surgery. Given the relatively small sample size, further larger studies are required for confirmation of our observations.     

Long-term survival and health-related quality of life of patients with ruptured abdominal aortic aneurysm.

INTRODUCTION: the outcome of ruptured abdominal aortic aneurysm (RAAA) patients is most frequently measured as operative or in-hospital mortality rate. However, survival alone is not an indicator of quality of the treatment. Assessment of quality of life (QoL) is used increasingly and is a relevant measure of outcome. OBJECTIVE:to assess long-term survival and QoL of patients undergoing repair of RAAA. DESIGN: follow-up study with cross-sectional QoL evaluation. MATERIALS AND METHODS: between 1996 and 2000, 199 of 220 patients with RAAA underwent surgery. Survivors were sent the generic the RAND 36-item Health Survey (RAND-36) self-administered questionnaire. RESULTS: total hospital mortality and operative mortality were 103 of 220 (47%) and 82 of 199 (41%). Of the 117 initial survivors, 21 were deceased at the time of the study. When compared to an age- and sex-adjusted general population, only physical functioning was significantly impaired (p=0.01) in the 82 of 93 (88%) RAAA survivors who responded. CONCLUSIONS: survivors after repair of RAAA had almost the same QoL as the norms of an age- and sex-adjusted general population, justifies an aggressive operative policy in RAAA.     

Consumption of mannan-binding lectin during abdominal aortic aneurysm repair.

OBJECTIVE: Patients undergoing abdominal aortic aneurysm (AAA) repair are exposed to an ischaemia-reperfusion injury (IRI), which is in part mediated by complement activation. We investigated the role of the novel lectin pathway of complement during IRI in patients undergoing AAA repair. METHODS: Patients undergoing elective open infrarenal AAA repair had systemic blood samples taken at induction of anaesthesia, prior to aortic clamping, prior to aortic declamping and at reperfusion. Control patients undergoing major abdominal surgery were also included. Plasma was assayed for levels of mannan-binding lectin (MBL) using ELISA techniques. Consumption of plasma MBL was used as a measure of lectin pathway activation. RESULTS: Twenty-three patients undergoing AAA repair and eight control patients were recruited. No lectin pathway activation could be demonstrated in the control patients. AAA patients experienced a mean decrease in plasma MBL levels of 41% representing significant lectin pathway activation (p = 0.003). CONCLUSION: Consumption of MBL occurs during AAA repair, suggesting an important role for the lectin pathway in IRI. Specific transient inhibition of lectin pathway activity could be of significant therapeutic value in patients undergoing open surgical AAA repair.     

Trends in cardiac morbidity and mortality after endoluminal abdominal aortic aneurysm repair; discussion 999-1000

HYPOTHESIS: The adverse cardiac event rate following endoluminal abdominal aortic aneurysm (EAAA) repair has decreased as experience in performing the procedure has increased. Aneurysm complexity affects the rate of adverse cardiac events. DESIGN AND PATIENTS: Data from 173 consecutive patients undergoing EAAA repair from 2 successive periods were compared. There were 82 patients in the early group (group 1) and 91 patients in the later group (group 2). MAIN OUTCOME MEASURES: Myocardial infarction, congestive heart failure, unstable angina, major dysrhythmias, death. RESULTS: The cardiac event rate was 8.5% for group 1 vs 16.5% for group 2 (P =.16). Predictors of adverse cardiac events on multivariate analysis were the use of 4 or more graft extensions (P =.04), female sex (P =.01), and number of Eagle risk factors (P<.001). There were 2 postoperative deaths (2.4%) in group 1 and 4 (4.4%) in group 2 (P =.7). CONCLUSIONS: Following EAAA repair: (1) adverse cardiac events were found to correlate with use of 4 or more graft extensions, female sex, and the number of Eagle risk factors; (2) cardiac morbidity and mortality remain significant despite greater experience and improved technology; and (3) operative mortality remains acceptably low.     

Identifying Patients With AAA With the Highest Risk Following Endovascular Repair

Introduction: It has been demonstrated that endovascular repair of arterial disease results in reduced perioperative morbidity and mortality compared to open surgical repair. The rates of complications and need for reinterventions, however, have been found to be higher than that in open repair. The purpose of this study was to identify the predictors of endograft complications and mortality in patients undergoing endovascular abdominal aortic aneurysm (AAA) repair; specifically, our aim was to identify a subset of patients with AAA whose risk of periprocedure mortality was so high that they should not be offered endovascular repair. Methods: We undertook a prospective review of patients with AAA receiving endovascular therapy at a single institution. Collected variables included age, gender, date of procedure, indication for procedure, size of aneurysm (where applicable), type of endograft used, presence of rupture, American Society of Anesthesiologists (ASA) class, major medical comorbidities, type of anesthesia (general, epidural, or local), length of intensive care unit (ICU) stay, and length of hospital stay. These factors were correlated with the study outcomes (overall mortality, graft complications, morbidity, and reintervention) using univariate and multivariate logistic regression. Results: A total of 199 patients underwent endovascular AAA repair during the study period. The ICU stay, again, was significantly correlated with the primary outcomes (death and graft complications). In addition, length of hospital stay greater than 3 days, also emerged as a statistically significant predictor of graft complications in this subgroup (P = .024). Survival analysis for patients with AAA revealed that age over 85 years and ICU stay were predictive of decreased survival. Statistical analysis for other subgroups of patients (inflammatory AAA or dissection) was not performed due to the small numbers in these subgroups. Conclusions: Patients with AAA greater than 85 years of age are at a greater risk of mortality following endovascular repair. In addition, patients who are expected to require postprocedure ICU admission are also at an increased risk of mortality following endovascular repair.     

A comparison of 50 initial endoluminal endograft repairs for abdominal aortic aneurysm with 50 concurrent open repairs

PURPOSE: To review the results of our initial experience with endovascular repair of abdominal aortic aneurysm (AAA) with respect to morbidity and mortality and to compare these outcomes with those of transabdominal repair. METHODS: We reviewed the first 50 consecutive endovascular AAA repairs performed at our institution from November 1999 to January 2002. Pre-operative risk factors, intraoperative variables and post-operative outcomes were assessed. All endovascular patients were followed with periodic examination, contrast-enhanced computed tomography and/or duplex scanning. Comparison was made to 50 patients undergoing standard open repair over a similar time period. RESULTS: Fifty patients underwent endovascular AAA repair (mean age 72.5, AAA size 5.5 cm). Endovascular devices employed were manufactured by Ancure (Guidant Corp.), and AneuRx (Medtronic). Preoperative risk factors were similar to patients undergoing transabdominal repair. Mean operative time was 169 minutes and estimated blood loss was 450cc with average blood replacement of.18 units. Median ICU stay was 0 days and mean hospital stay was 2.3 nights. There were no conversions to open repair, however there was one aborted endovascular attempt. Morbidity included MI (2%), colon ischemia (1%), acute renal insufficiency (4%) and leg ischemia (4%). There was one death within 30 days. Seven endoleaks were identified (6 type II and 1 type I) and were managed angiographically. CONCLUSIONS: The short-term surgical morbidity and mortality rates for endovascular repair of AAA are acceptably low and are comparable to the transabdominal approach.