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.     

Validity of the Glasgow Aneurysm Score and the Hardman Index in predicting outcome after ruptured abdominal aortic aneurysm repair

BACKGROUND: The Glasgow Aneurysm Score and the Hardman Index have been recommended as predictors of outcome after repair of ruptured abdominal aortic aneurysm (AAA). This study aimed to assess their validities. METHODS: Patients admitted to a single unit with a ruptured AAA over a 2-year interval (2000-2001) were identified from a prospectively compiled database. Hospital records of all patients undergoing attempted operative repair were reviewed. The Glasgow Aneurysm Score and the Hardman Index were calculated retrospectively and related to clinical outcome. RESULTS: One hundred patients were admitted with a ruptured AAA. Of these, 82 underwent attempted operative repair and were included in the study: 68 men and 14 women, of median age 73 (range 54-87) years. Thirty (37 per cent) patients died after the operation. The Glasgow Aneurysm Score was a poor predictor of postoperative mortality. The area under the Receiver-Operator Characteristic curve was 0.606 (P = 0.112, 95 per cent c.i. 0.483-0.729). Similarly, the Hardman Index failed to predict postoperative mortality accurately (P = 0.211, chi(2) for trend). Of nine patients in this series with three or more Hardman criteria, generally held to be fatal, six survived. CONCLUSION: Contrary to previous reports, The Glasgow Aneurysm Score and the Hardman Index were poor predictors of postoperative mortality after repair of a ruptured AAA in this study.     

Glasgow Aneurysm Score as a predictor of immediate outcome after surgery for ruptured abdominal aortic aneurysm

BACKGROUND: The aim of the study was to assess the value of the Glasgow Aneurysm Score in predicting postoperative death after repair of a ruptured abdominal aortic aneurysm (AAA). METHODS: Between 1991 and 1999, 836 patients underwent surgery for ruptured AAA. Their operative risk at presentation was evaluated retrospectively using the Glasgow Aneurysm Score, based on data from the nationwide Finnvasc registry. RESULTS: The operative mortality rate was 47.2 per cent (395 of 836); 164 patients (19.6 per cent) had cardiac complications and 164 (19.6 per cent) required intensive care treatment for more than 5 days. Predictors of postoperative death in univariate analysis were: coronary artery disease (P = 0.005), preoperative shock (P < 0.001), age (P < 0.001), and the Glasgow Aneurysm Score (P < 0.001). In multivariate analysis the predictors were: preoperative shock (odds ratio (OR) 2.13 (95 per cent confidence interval (c.i.) 1.45 to 3.11); P < 0.001) and the Glasgow Aneurysm Score (for an increase of ten units: OR 1.81 (95 per cent c.i. 1.54 to 2.12); P < 0.001). Receiver-operator characteristic (ROC) curves showed that the best cut-off value of the Glasgow Aneurysm Score in predicting postoperative death was 84 (area under the curve 0.75 (95 per cent c.i. 0.72 to 0.78), standard error 0.17; P < 0.001). The operative mortality rate was 28.2 per cent (114 of 404) in patients with a Glasgow Aneurysm Score of 84 or less, compared with 65.0 per cent (281 of 432) in those with a score greater than 84 (P < 0.001). CONCLUSION: The Glasgow Aneurysm Score predicted postoperative death after repair of ruptured AAA in this series.     

Applicability of Glasgow Aneurysm Score and Hardman Index to elective endovascular abdominal aortic aneurysm repair

OBJECTIVE: This retrospective study aimed to explore the role of Glasgow Aneurysm Score (GAS) and Hardman Index (HI) in predicting outcome after elective endovascular aneurysm repair (EVAR). METHODS: All 71 patients who underwent elective EVAR in a single centre over 9 years were reviewed. Clinical data were used to classify patients into the three standard GAS tertiles and to score patients according to the HI. RESULTS: Fifty-one patients scored > or = 77 according to GAS. Actual and predicted mortality in this group were 3.9% and 9.3%. Seventeen patients scored between 69 and 77 with actual and predicted mortality of 0% and 4.1%. Three patients scored less than 69 with actual and predicted mortality of 0% and 2.4%. Ten patients scored > or = 3 on the HI with actual and predicted mortality of 10% and 100%, respectively. Twenty-four patients scored 2 with actual and predicted mortality of 4.2% and 55%. Twenty-seven patients scored 1 with actual and predicted mortality of 0% and 28%, respectively. Ten patients scored 0 with actual and predicted mortality of 0% and 16%, respectively. The chi(2) test showed extremely significant p value of 0.0001 in case of HI, and p value of 0.0800 for GAS, slightly less significant, probably due to the small sample size. CONCLUSION: Contrary to their role in ruptured and open aortic aneurysm repair, GAS and HI overestimate both mortality and morbidity following EVAR and are poor predictors of outcome.     

Comparison of risk-scoring methods in predicting the immediate outcome after elective open abdominal aortic aneurysm surgery.

BACKGROUND & OBJECTIVES: The aim of this study was to apply three simple risk - scoring systems to prospectively collected data on all elective open Abdominal Aortic Aneurysm (AAA) operations in the Cambridge Academic Vascular Unit over a 6 - year period (January 1998 to January 2004), to compare their predictive values and to evaluate their validity with respect to prediction of mortality and post-operative complications. METHODS: 204 patients underwent elective open infra-renal AAA repair. Data were prospectively collected and risk assessment scores were calculated for mortality and morbidity according to the Glasgow Aneurysm Score (GAS), VBHOM (Vascular Biochemistry and Haematology Outcome Models) and Estimation of Physiologic Ability and Surgical Stress (E-PASS). RESULTS: The mortality rate was 6.3% (13/204) and 59% (121/204) experienced a post-operative complication (30-day outcome). For GAS, VBHOM and E-PASS the receiver operating characteristics (ROC) curve analysis for prediction of in-hospital mortality showed area under the curve (AUC) of 0.84 (95% confidence interval [CI], 0.76 to 0.92; p<0.0001), 0.82 (95% CI, 0.68 to 0.95; p=0.0001) and 0.92 (95% CI, 0.87 to 0.97; p<0.0001) respectively. There were also significant correlations between post-operative complications and length of hospital stay and each of the three scores, but the correlation was substantially higher in the case of E-PASS. CONCLUSIONS: All three scoring systems accurately predicted the risk of mortality and morbidity in patients undergoing elective open AAA repair. Among these, E-PASS seemed to be the most accurate predictor in this patient population.     

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.     

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.     

Positive fluid balance is associated with complications after elective open infrarenal abdominal aortic aneurysm repair.

BACKGROUND: Open abdominal aortic aneurysm (AAA) repair is associated with cardiac and respiratory complications and an overall mortality rate of 2 to 8%. We hypothesised that excessive fluid administration during the perioperative period contributes to complications and poor outcome after AAA repair. METHODS: This was a retrospective cohort study. Medical records were analysed for fluid balance and complications in 100 consecutive patients treated by open AAA repair at a single centre between 2002-2005. Mortality and all major adverse events (MAE) such as myocardial infarction (MI), cardiac arrhythmia (Arr), pulmonary oedema (PO), pulmonary infection (PI), and acute renal failure (ARF) were included in the analysis. Level of care and hospital stay, were also recorded. RESULTS: There were no in-hospital deaths. MAE occurred in 40/100 (40%): MI (6%); Arr (14%); PO (14%); PI (25%); ARF (8%). Complications were not predicted by preoperative cardiovascular risk factors, operative and clamp time, or blood loss. Patients with complications had significantly greater cumulative positive fluid balance on postoperative day 0 (p<0.01), day 1 (p<0.05), day 2 (p<0.03) and day 3 (p<0.04). This relationship also existed for individual complications such as MI, and pulmonary oedema. These patients had significantly longer ICU/HDU (p<0.002) and hospital stay (p<0.0001). CONCLUSIONS: Serious complications are common after elective open AAA repair, and we have shown that positive fluid balance is predictive of major adverse events increased HDU/ICU and overall hospital stay.     

The influence of aneurysm size on perioperative cardiac outcome in elective open infrarenal aortic aneurysm repair

BACKGROUND: Abdominal aortic aneurysm (AAA) size and growth has been found to be associated with local generation of inflammation markers such as interleukin-6. Inflammation also seems to be important in perioperative adverse cardiac events. We hypothesized that patients with a large AAA are at increased risk for cardiac events. METHODS: Consecutive patients who underwent a computed tomography angiography scan before open elective infrarenal AAA repair between March 2000 and December 2005 at three hospitals were analyzed. All patients were screened for the clinical risk factors of age, gender, angina pectoris, myocardial infarction, heart failure, diabetes, stroke, renal failure, and chronic obstructive pulmonary disease, as well as for cardioprotective medication. Postoperative data on troponin release, creatine kinase/creatine kinase isoenzyme MB, and electrocardiogram were routinely collected on days 1, 3, 7, and 30. The main outcome measure was the combined end point of 30-day cardiovascular death and nonfatal myocardial infarction. Multivariate Cox regression analysis was used to evaluate the influence of AAA size on postoperative cardiac outcome. RESULTS: The study included 500 patients. Their mean age was 69.8 +/- 9.5 years, and 431 (86%) were men. Thirty-one patients (6.2%) had perioperative cardiovascular complications, consisting of 15 (3.0%) cardiovascular deaths and 16 (3.2%) nonfatal myocardial infarctions. After correction for other risk factors, including age, Revised Cardiac Risk Index, medication use, duration of surgery, and intraoperative blood loss, AAA size was independently associated with perioperative nonfatal myocardial infarction and cardiovascular death (3.2% increase in risk for each millimeter added, 95% confidence interval 1.1% to 6.2%, P = .007). CONCLUSION: A larger AAA size is independently associated with an increased incidence of perioperative cardiovascular complications after elective infrarenal AAA repair.     

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.     

Improved long-term survival following infrarenal abdominal aortic aneurysm repair

Background. The aim was to investigate early and long-term results following AAA repair during a 20-year period. Method. One thousand and forty one patients with AAA were treated with open surgery (905) or EVAR (136) during the period 1983–2002. Comorbidity and factors influencing early and long-term results were investigated. Data were collected retrospectively from the patients’ medical records. A complete follow-up was obtained. Results. Women had a significantly higher 30-day mortality following repair of ruptured AAA than men. The degree of emergency, advancing age and renal failure were significantly associated with 30-day mortality. We observed an improvement in long-term survival during the study period. Time interval of surgery, cerebrovascular disease, diabetes, COPD and renal failure influenced long-term survival negatively. Conclusion. Women with ruptured AAA have a higher early mortality than men, which needs to be investigated further. Long-term survival has improved during the study period. Age, diabetes, chronic obstructive pulmonary disease, renal failure and cerebrovascular insufficiency influenced the long-term survival negatively. EVAR is used to an increasing extent and the results are improving.     

Microalbuminuria and deterioration of renal function after elective repair of infrarenal abdominal aortic aneurysm

AIMS: Renal dysfunction affects the prognosis of patients after aortic surgery. However, the factors associated with the postoperative deterioration of renal function has not been clarified precisely. METHOD: We prospectively examined renal function in 80 patients (age: 73 +/- 7 years, 66 males) who required the elective repair of infrarenal abdominal aortic aneurysm (AAA). Serum creatinine (Scr) was measured. 24-h-creatinine clearance (Ccr) and urinary albumin excretion (UAE) were determined. Renal volume and mean renal length were calculated using the data obtained by ultrasonography. 48 patients showed normal UAE (< 30 mg/day), and 24 had microalbuminuria (30-300 mg/day) and 8 had overt proteinuria (> 300 mg/day). Scr were 0.9 +/- 0.4, 1.0 +/- 0.3 and 2.1 +/- 1.3 mg/dl, respectively. RESULTS: On Day 5 after surgery, 12 patients (15%) showed deterioration of renal function as defined either by an increase in Scr (> or = 0.5 mg/dl) or by a decrease in Ccr > or =20%). The acute deterioration of renal function was related to mean renal volume, mean renal length, duration of operation and the use of antibiotics. At Month 12 after surgery, Scr increased in the overt proteinuria group. The deterioration of renal function at Month 12 was found in 8 patients (10%) with microalbuminuria or overt proteinuria, and related to preoperative Ccr, UAE, mean renal volume, mean renal length, smoking status and blood pressure. CONCLUSION: We conclude that the deterioration of renal function occurred in considerable number of patients with AAA after elective operation on acute and chronic phase, although the development of end-stage renal failure is rare. Factors related to the acute and late deterioration appears to be different. UAE and renal size should be measured, even if Scr is in normal range at preoperative observation.     

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.     

Tetraplegia after elective abdominal aortic aneurysm repair

Spinal cord ischemia after elective infrarenal aortic aneurysm repair is extremely rare, and documented cases that are described are of paraplegia. This case of tetraplegia occurred in a 64-year-old man with disabling claudication after an aortobifemoral graft repair for occlusive disease associated with a 5-cm infrarenal aneurysm. Magnetic resonance imaging supported lower cervical spinal cord ischemia, an unusual area for ischemia during aortic clamping since this area is usually most resistant. Because the lower thoracic and upper lumbar region, typically T8, is more susceptible to ischemia due to the variable collateral spinal cord circulation, the level of clamping was unlikely to be responsible. Other causes are considered. It was likely to be multifactorial and illustrates the need for great attention to detail in perioperative management and patient consent.     

Myocardial damage in high-risk patients undergoing elective endovascular or open infrarenal abdominal aortic aneurysm repair.

OBJECTIVE: Dobutamine stress echocardiography (DSE) provides an objective assessment of the presence and extent of coronary artery disease. Therefore we compared cardiac outcome in patients at high-cardiac risk undergoing open or endovascular repair of infrarenal AAA using preoperative DSE results. METHODS: Consecutive patients with >or=3 cardiac risk factors (age >70 years, angina pectoris, myocardial infarction, heart failure, stroke, renal failure, and diabetes mellitus) undergoing infrarenal AAA repair were reviewed retrospectively. All underwent cardiac stress testing using DSE. Postoperatively data on troponin release and ECG were collected on day 1, 3, 7, before discharge, and on day 30. The main outcome measures were perioperative myocardial damage and myocardial infarction or cardiovascular death. RESULTS: All 77 patients (39 endovascular, 38 open) had a history of cardiac disease. The number and type of cardiac risk factors were similar in both groups. Also DSE results were similar: 55 vs 56%, 24 vs 28%, and 21 vs 18% had no, limited, or extensive stress induced myocardial ischemia respectively. The incidence of perioperative myocardial damage (47% vs 13%, p=0.001) and the combination of myocardial infarction or cardiovascular death (13% vs 0%, p=0.02) was significantly lower in patients receiving endovascular repair. CONCLUSION: In patients with similar high cardiac risk, endovascular repair of infrarenal aortic aneurysms is associated with a reduced incidence of perioperative myocardial damage.