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.     

Long-Term Survival and Quality of Life After Open Abdominal Aortic Aneurysm Repair

Background

Open repair of abdominal aortic aneurysm (AAA) generally involves postsurgery admission to the intensive care unit (ICU). Few studies have evaluated the impact of surgery for either ruptured or nonruptured AAA (with postoperative ICU treatment) on long-term survival and quality of life. The primary aim of this study was to quantify long-term survival and health-related quality of life (HrQpL) of a cohort of patients undergoing open AAA repair after hospital discharge.

Methods

Consecutive patients undergoing open elective or acute AAA reconstruction with postoperative admission to the ICU and discharged alive from the hospital during 2009 were identified. Primary outcome measures were 1-year and long-term mortality. The secondary outcome was the HrQoL using the EuroQol-6D (EQ-6D) questionnaire at the end of the follow-up period.

Results

A total of 263 patients were treated and postoperatively discharged alive: 56 had a ruptured AAA (rAAA), 35 a symptomatic AAA, and 172 an asymptomatic AAA. The 1-year mortality after open AAA repair was 8 %. Overall, 39 % of patients died within 10 postoperative years (mean 6.0 ± 2.8 years). Long-term survival of patients with a ruptured or symptomatic aneurysm was similar to that of patients undergoing elective aneurysm repair. Long-term HrQoL of the total study population was worse than that of an age-matched general Dutch population on the EQ-us (range 0–1, difference 0.12). This decrease in HrQoL was mainly seen in mobility, self-care, usual activities, and cognition.

Conclusions

Ten years after open AAA repair, the overall survival rate was 59 %. Long-term survival and HrQoL were similar for patients with a repaired ruptured or symptomatic aneurysm and those who underwent elective aneurysm repair. There were also no differences in patients with infrarenal versus juxtarenal/suprarenal aneurysms. Surviving patients had a lower HrQoL than the age-matched general Dutch population, especially regarding mobility, self-care, usual activities, and cognition.     

Quality of life following surgery for abdominal aortic aneurysm.

Repair of abdominal aortic aneurysm (AAA) carries a considerable rate of morbidity and mortality, but little information exists on the quality of life following this procedure. During 1988 and 1989, in two hospitals, 211 patients (186 men and 25 women; median age 74 (range 48-87) years) underwent surgery for AAA. There were 77 ruptured aneurysms and 134 electively repaired. Of these, 38 patients died in hospital (27 ruptured, 11 elective); by the time of review a further eight (one ruptured, seven elective) had died from unrelated causes. Of the 165 survivors, 131 (45 ruptured, 86 elective) were reviewed and questioned as to their physical and mental state before and after surgery. Using the Rosser index, a value for quality of life before and after surgery was calculated (1.0, good; 0, dead). The value for the elective group was 0.94 before operation and 0.96 after, but in the ruptured group fell from 0.98 before surgery to 0.87 afterwards. This study shows that patients undergoing elective surgery for repair of AAA retain good quality of life. By contrast, patients surviving emergency surgery following this procedure seem to suffer a deterioration in life quality, which must be endured for the same expected lifetime as that for the elective group. These results support the need for a national AAA ultrasonographic screening programme.     

Plasma endothelin levels and outcome in patients undergoing repair of ruptured infrarenal abdominal aortic aneurysm

BACKGROUND: Endothelin-1 (ET-1) is the most potent known vasoconstrictor. Elevated plasma levels have been demonstrated in patients with myocardial infarction, cardiogenic and septic shock, and respiratory, heart, and kidney failure, as well as in those undergoing elective abdominal aortic aneurysm (AAA) repair. However, endothelin levels have not previously been examined in patients undergoing repair of ruptured AAA. We hypothesized that hemorrhagic shock, lower torso ischemia, and reperfusion associated with ruptured AAA repair lead to increased synthesis and secretion of ET-1, which, in turn, predispose to organ failure, one of the principal causes of death in this condition. METHODS: Fourteen patients were studied. Plasma levels of big ET-1 and ET-1 were measured immediately before operation and immediately before, 5 minutes, and 6 hours after aortic clamp release. RESULTS: All patients survived for at least 24 hours after operation. Big ET-1 levels were above the normal range at one or more sample points in all patients, and the ET-1 levels were above the normal range in all survivors and four of five nonsurvivors. Five patients who died of organ failure had significantly lower big ET-1 levels at all sample points and significantly lower ET-1 levels after 5 minutes of reperfusion when compared with survivors. Preoperative ET-1 levels were significantly lower in eight patients who subsequently developed kidney failure than in six patients who did not. CONCLUSION: Contrary to our original hypothesis, these novel data demonstrate that patients with ruptured AAA in whom fatal postoperative organ failure develops have significantly lower perioperative endothelin levels than survivors.     

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.     

Aneurysm rupture is independently associated with increased late mortality in those surviving abdominal aortic aneurysm repair

PURPOSE: The aim of this study was to define whether veterans who survived repair of ruptured abdominal aortic aneurysms (AAA) experienced late survival rates similar to those surviving repair of intact AAA. METHODS: All veterans undergoing AAA repair in DRGs 110 and 111 during fiscal years 1991-1995 were identified using the Veterans Affairs (VA) Patient Treatment File (PTF). Late mortality was defined using VA administrative databases including the Beneficiary Identification and Record Locator System and PTF. Illness severity and patient complexity were defined using PTF discharge data that were further analyzed by Patient Management Category software. Veterans were followed up to 6 years after AAA repair. RESULTS: During the study, 5833 veterans underwent repair of intact AAA while 427 had repair of ruptured AAA in all VA medical centers. Operative mortality was defined as that which occurred within 30 days of surgery or during the same hospitalization as aneurysm repair. For those undergoing repair of intact AAA, operative mortality thus defined was 4.5% (265/5833). Operative mortality was 46% (195/427) after repair of ruptured AAA. Overall mortality (including operative mortality) during 2.62+/-1.61 years follow-up was 22% (1282/5833) with intact AAA versus 61% (260/427) for those with ruptured AAA (P<0.001). Further analysis of survival outcomes was performed in patients who survived AAA repair (i.e., those who were discharged alive and lived 30 days or more after surgery). Of those who initially survived repair of ruptured AAA, 28% (65/232) died during follow-up versus 18% (1017/5568) who initially survived repair of intact AAA (odds ratio 1.74; 95% confidence limits 1.30-2.34; P<0.001). In those initially surviving AAA repair, stepwise logistic regression analysis revealed that increasing age, illness severity, patient complexity, as well as AAA rupture and aortic graft complications were increasingly and independently associated with late mortality. Mean survival time was 1681 days for those who survived >30 days and who were discharged alive after repair of ruptured AAA versus 1821 days for those who initially survived repair of intact AAA (P< 0.001). CONCLUSIONS: In addition to higher postoperative mortality rates with ruptured AAA, mortality during follow-up for survivors of AAA repair was also greater for those who survived repair of ruptured AAA. The toll taken by ruptured abdominal aortic aneurysms did not end in the immediate postoperative period.     

Ruptured abdominal aortic aneurysm: long-term survival]

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

The impact of race and insurance type on the outcome of endovascular abdominal aortic aneurysm (AAA) repair

BACKGROUND: Although mortality and complication rates for abdominal aortic aneurysm (AAA) have declined over the last 20 years, operative complication rates and perioperative mortality are still high, specifically for repair of ruptures. The goal of this study was to determine the influence of insurance type and ethnicity while controlling for the influences of potential confounders on procedure selection and outcome following endovascular AAA repair (EVAR). METHODS: Using the Nationwide Inpatient Sample (NIS) database, we identified patients who underwent EVAR repair of ruptured and elective infrarenal AAA, between 1990 and 2003. Insurance type and ethnicity were analyzed against the primary outcome variables of mortality and major complications. The potential confounders of age, gender, operative location, diabetes, and Deyo index of comorbidities, were controlled. RESULTS: Bivariate analyses demonstrated significant differences between insurance types and ethnicity and mortality and complications. Patients who were self pay had adverse outcomes in comparison to Private insurance. Whites encountered less perioperative mortality and postoperative complications than Blacks and Hispanics. CONCLUSIONS: After controlling for previously identified associative factors for AAA outcome, ethnicity and insurance type does influence EVAR surgical outcome. Subsequent studies that break down emergent repair vs elective surgery and that longitudinally stratify delay in surgery, or time to admission may be useful.     

Outcome and Survival of Patients Aged 65 Years and Younger after Abdominal Aortic Aneurysm Rupture

Advanced age (> 80 years) confers a survival disadvantage after operative repair of a ruptured abdominal aortic aneurysm (AAA). This study aimed to determine if young age (≤65 years) confers a survival benefit. Consecutive patients undergoing attempted repair of a ruptured AAA between 1995 and 2001 were included in the study. Demographic, clinical, and operative factors were analyzed together with in-hospital mortality, duration of postoperative hospital stay, and long-term survival. Of 378 patients admitted with a ruptured AAA, 52 (14%) were ≤ 65 years of age and 326 (86%) were > 65 years. There were 4 (8%) women in the younger cohort compared to 74 (23%) women in the older group (p = 0.015). Four (8%) patients in the younger group were thought to be unsuitable for surgical repair compared to 77 (24%) patients in the older cohort (p = 0.009). Of the 48 younger patients who underwent attempted operative repair, 22 (46%) died in hospital, compared to 108 (43%) of 249 patients > 65 years (p = 0.753). The median (range) postoperative hospital stay of survivors was 11 days (6–59 days) in the younger cohort and 15 days (6–121 days) in the older group (p = 0.005). Patients ≤ 65 years of age undergoing operative repair of ruptured AAA have no survival advantage over older patients. These data support AAA screening for the “at risk” and age-defined population. This work was presented to the 53^rd International Congress of the European Society for Cardiovascular Surgery, Ljubljana, 2004 and published in abstract form in Interactive Cardiovascular and Thoracic Surgery 2004;3(S1):81.     

Ruptured inflammatory abdominal aortic aneurysm: insights in clinical management and outcome

BACKGROUND: Ruptured inflammatory abdominal aortic aneurysm (AAA) is relatively rare, and little has been written on the outcome of operative treatment. METHODS: Patients undergoing attempted repair of ruptured inflammatory AAA between 1995 and 2001 were included in a retrospective case-cohort study. Demographic, clinical, and operative factors were analyzed, together with in-hospital morbidity, in-hospital mortality, and duration of postoperative hospital stay. RESULTS: Of 297 patients who underwent attempted operative repair of ruptured AAA, 24 (8%) had an inflammatory aneurysm. Twenty-two patients were men, and two were women; median age was 69 years (range, 51-85 years). Operative findings revealed a contained hematoma in 16 patients (70%), free rupture in 3 patients (13%), aortocaval fistula in 4 patients (17%), and aortoenteric fistula in 1 patient (4%). Of 273 noninflammatory ruptured AAAs, only 2 AAA (1%) were associated with primary aortic fistula. Ten patients (42%) with inflammatory AAA died in hospital, compared with 117 of 273 patients (43%) without inflammation. Median postoperative stay was 10 days (range, 0-35 days). Of the 14 patients with inflammatory lesions who survived, 11 had postoperative complications; 4 patients had acute renal failure, three of whom required temporary renal replacement therapy. CONCLUSIONS: Ruptured inflammatory AAA is associated with a higher incidence of aortic fistula than is ruptured noninflammatory AAA. Repair of ruptured inflammatory AAA is not associated with increased operative mortality compared with repair of ruptured noninflammatory AAA.     

Outcome and Quality of Life in Patients Treated for Abdominal Aortic Aneurysms: A Single Center Experience

BACKGROUND: Durability of protection and long-term quality of life (QoL) are critical outcome parameters of abdominal aortic aneurysm (AAA) repair. The aim of the present study was to compare results of endovascular and open aneurysm repair (EVAR and OR) with adjusted standard populations, including stratification for urgency of presentation. METHODS: Retrospective analysis of prospectively collected data of 401 consecutive patients presenting with AAA between January 1998 and December 2002. Cross-sectional follow up was 58 +/- 29 months. Patients were grouped into three cohorts: elective EVAR (n = 68), elective OR (n = 244), and emergency OR (including symptomatic and ruptured AAA, n = 89). Endpoints were perioperative (i.e., 30 days or in-hospital) and late mortality rates, as well as long-term QoL as assessed by the Short Form health survey questionnaire (SF-36). RESULTS: Mean age was lower in the elective OR cohort (66 +/- 10 years) than in the EVAR cohort (72 +/- 7 years; p < .05). Perioperative mortality rates were 4.4%, 0.4%, and 10.1%, for the EVAR, elective OR, and emergency OR cohorts, respectively (p < .05). Corresponding cumulative survival rates after 4 years were 67%, 89%, and 69%, respectively. Long-term QoL SF-36 scores were in all cohorts similar to age- and gender-adjusted standard populations, which score between 85 and 115: 99.6 +/- 35.8 (EVAR), 101.3 +/- 32.4 (elective OR), and 100.4 +/- 36.5 (emergency OR). CONCLUSIONS: Long-term QoL is not permanently impaired after AAA repair, but returns in long-term survivors to what would be expected in a standard population. In this respect, differences were found neither between EVAR and OR, nor between elective and emergency repair. Perioperative mortality rates were highest in patients undergoing emergency OR. The outlook for such patients after the perioperative period, however, was similar to that for patients undergoing elective repair.     

Long-term survival and quality of life following ruptured abdominal aortic aneurysm

To document both the long-term survival and the quality of life of patients following surgery for ruptured abdominal aortic aneurysm (AAA), the records of 65 patients with ruptured AAA resection were compared with those of 100 who underwent elective AAA resection. The actuarial survival following ruptured aneurysm surgery was 92%, 51%, and 51% at 1, 5, and 10 years, respectively, and did not differ statistically for patients after elective AAA surgery or for an age- and sex-matched sample from the general population. Based on responses to a quality of life survey, there were no discernible differences in life-style, degree of independence, or productivity following either ruptured or elective AAA surgery. Survivors of ruptured AAA have an excellent long-term prognosis and expectation for a good quality of life.     

Epidemiological study of the relationship between volume and outcome after abdominal aortic aneurysm surgery in the UK from 2000 to 2005

BACKGROUND: The aim was to assess the relationship between hospital volume and outcome after abdominal aortic aneurysm (AAA) surgery in the UK. METHODS: Hospital Episode Statistics (2000-2005) were classified as elective, urgent or ruptured AAA repair. Analysis was by modelling of mortality rate, complication rate and length of hospital stay with regard to the annual operative volume, after risk adjustment. RESULTS: There were 112,545 diagnoses, or repairs, of AAAs, of which 26,822 were infrarenal aneurysms. The mean mortality rate was 7.4, 23.6 and 41.8 per cent for elective, urgent and ruptured AAA repair respectively. Elective AAA repair undertaken at high-volume hospitals showed volume-related improvements in mortality (P < 0.001). Patients were discharged from hospital earlier (P < 0.001). The critical volume threshold was 32 elective AAA repairs per year. For urgent repair, patients at high-volume hospitals had a reduced mortality rate (P = 0.017) with an increased length of stay (P = 0.041). There was no relationship between volume and outcome for ruptured AAA repairs. CONCLUSION: Increased annual volumes were associated with significant reductions in mortality for elective and urgent AAA repair, but not for repair of ruptured AAAs.     

The systemic inflammatory response syndrome,organ failure,and mortality after abdominal aortic aneurysm repair

BACKGROUND: Organ failure is a major cause of morbidity and mortality after abdominal aortic aneurysm (AAA) repair. The aim of this study was to determine the relationships between the systemic inflammatory response syndrome (SIRS), organ failure, and mortality after AAA repair and to determine whether the clinical monitoring of SIRS was a useful adjunct to clinical method. METHODS: One hundred consecutive patients undergoing open AAA repair were prospectively studied. Patients were divided into three groups: those undergoing elective AAA repair, those with symptomatic but nonruptured AAA, and those with ruptured AAA. The presence of SIRS and organ failure was recorded on a daily basis for each patient until discharge or death. RESULTS: Most patients had SIRS develop during the postoperative period: 89% of the elective group, 92% of the emergency nonruptured (urgent) group, and 100% of the ruptured group. Multiorgan failure occurred in 3.8% of the elective group, 38% of the urgent group, and 64% of the ruptured AAA group. After ruptured AAA repair, the concurrent absence of both SIRS and any organ failure for 48 hours had a sensitivity of 93% and a specificity of 91% as a predictive indicator of subsequent survival to hospital discharge. Patients in whom multiorgan failure developed after ruptured AAA repair had a significantly higher mortality rate (69%) than those who did not (0%; P =.001; 95% CI for the difference, 30.2% to 85.8%). CONCLUSION: The differences in the incidence rate of multiorgan failure between the patient groups compared with the high incidence rate of SIRS in all patient groups supports the two-hit hypothesis of multiorgan failure. The presence of multiorgan failure after ruptured AAA repair is associated with poor outcome. The absence of SIRS and organ failure in these patients is a good predictive indicator of survival.     

A cost analysis of surgery for ruptured abdominal aortic aneurysm.

OBJECTIVE: This study compares our costs of salvaging patients with ruptured abdominal aortic aneurysms (AAA) with the costs for unruptured AAAs. METHODS: Details of all AAAs presenting over 18 months were obtained. Costs of repair were carefully calculated for each case and were based upon ITU and ward stay and the use of theatre, radiology and pathology services. We compared the costs in unruptured AAAs with both uncomplicated ruptures and ruptures with one or more system failure. RESULTS: The mortality rate for ruptures undergoing repair was 18% and for elective repairs was 1.6%. The median cost for uncomplicated ruptures was 6427 Pounds (range 2012-13,756 Pounds). For 12 complicated ruptures, it was 20,075 Pounds (range 13,864-166,446 Pounds), and for 63 unruptured AAAs, was 4762 Pounds (range 2925-47,499 Pounds). CONCLUSION: Relatively low operative mortality rates for ruptured AAA repair can be achieved but this comes at substantial cost. On average, a ruptured AAA requiring system support costs four times as much as an elective repair.     

POSSUM models in open abdominal aortic aneurysm surgery.

OBJECTIVES: This study evaluated the Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM), Portsmouth (P) POSSUM and Vascular (V) POSSUM. The primary aim was to assess the validity of these scoring systems in a population of patients undergoing elective and emergency open AAA repair. The secondary intention was in the event that these equations did not fit all patients with an aneurysm; a new model would be developed and tested using logistic regression from the local data (Cambridge POSSUM). METHODS: POSSUM data items were collected prospectively in a group of 452 patients undergoing elective and emergency open AAA repair over an eight-year period. The operative mortality rates were compared with those predicted by POSSUM, P-POSSUM, V-POSSUM and Cambridge POSSUM. RESULTS: All models except V-POSSUM (physiology only) showed significant lack of fit when predicting mortality after open AAA surgery. It was found that the locally generated single unified model (Cambridge POSSUM) could successfully describe both elective and ruptured AAA mortality with good discrimination (chi(2)=9.24, 7 d.f., p=0.236, c-index=0.880). CONCLUSIONS: POSSUM, V-POSSUM and P-POSSUM may not be robust tools for comparing mortality between populations undergoing elective and emergency open AAA repair as once thought. The development and successful validation of Cambridge POSSUM provides a unified model to describe both elective and emergency AAAs together and should be validated in other geographical settings.     

Abdominal aortic aneurysm repair in octogenarians: myth or reality?

AIM: We studied the thirty-day mortality and morbidity rate to assess the value of conventional open repair vs endovascular aortic repair (EVAR) in an elderly population presenting with a ruptured, symptomatic or asymptomatic abdominal aortic aneurysm (AAA) undergoing emergency, urgent or elective repair. METHODS: During the period from January 2004 to May 2007, 329 consecutive patients were treated for AAA in our Department. Among these, 81 (24.6%) were aged >80 years (mean age 83.6, range 80-95 years). These older patients were divided into groups according to their clinical presentation: ruptured AAA group (rAAA) - 22 cases (4 emergency EVAR, 18 emergency open repair); symptomatic non-ruptured AAA group (sAAA) - 15 cases (11 urgent EVAR, 4 urgent open repair); asymptomatic AAA group (asAAA) - 44 cases (32 elective EVAR, 12 elective open repair). The main outcome measures were 30-day mortality and 30-day morbidity rate. RESULTS: The mortality rate following open surgery vs EVAR was 66.6% vs 50% (P=NS) in the rAAA group, 25% vs 0% (P=NS) in the sAAA group, and 9% vs 3.2% (P=NS) in the asAAA group. When comparing postoperative morbidities in the octogenarians, 3 of the patients that received EVAR (6.4%) and 15 of those that received open repair (48.4%) had a severe complication (P<0.01). CONCLUSION: The introduction of EVAR has considerably changed the balance of risks and benefits for AAA treatment. Our study confirms the high mortality rate for octogenarians with rAAA and haemodynamic instability, and supports the value of an active EVAR approach for octogenarians with AAA to prevent rupture. Moreover, the introduction of endovascular techniques as part of an overall treatment algorithm for ruptured AAAs appears to be potentially associated with improved outcomes in terms of mortality and morbidity as compared to open surgical repairs alone.     

Initial experience of abdominal aortic aneurysm repairs in Borneo

Background: Abdominal aortic aneurysms (AAA) repairs are routineoperations with low mortality in the developed world. There arefew studies on the operative management of AAA in the Asian population.This study reports the initial results from a unit with no previousexperience in this surgery by a single surgeon on completion oftraining. Methods: All patients with AAA repair from a prospective databasebetween 1996 and 1999 in the south‐east Asian state of Sarawak inBorneo Island were analyzed. Three groups were identified on presentationaccording to clinical urgency of surgery. Elective surgery was offeredto all good risk patients with AAA of ≥ 5 cm.All symptomatic patients were offered surgery unless contraindicatedmedically. Results: AAA repairs were performed in 69 patients: 32 (46%)had elective repairs of asymptomatic AAA; 20 (29%) hadurgent surgery for symptomatic non‐ruptured AAA; and 17 (25%)had surgery for ruptured AAA. The mortality rate for elective surgery was6%; the two deaths occurred early in the series with thesubsequent 25 repairs recorded no further mortality. The mortalityrates for the urgent, symptomatic non‐ruptured AAA repair and rupturedAAA repair were 20% and 35%, respectively. Cardiacand res­piratory complications were the main morbidities.Sixty‐three patients seen during this period had no surgery; threepresented and died of ruptured AAA, 34 had AAA of ≤ 5 cmin diameter, and 26 with AAA of ≥ 5 cmdiameter had either no consent for surgery or serious medical contraindications. Conclusion: This study showed that AAA can be repaired safely byhighly motivated and adequately trained surgeons in a hospital withlittle previous experience.     

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.     

Optimal timing of abdominal aortic aneurysm repair after coronary artery revascularization.

OBJECTIVE: The authors ascertained the optimal timing of repair of an abdominal aortic aneurysm (AAA) after coronary artery revascularization. SUMMARY BACKGROUND DATA: Cardiac events are the most common cause of death after elective repair of AAA. Preoperative coronary revascularization has significantly reduced postoperative cardiac complications after elective AAA repair. Currently, most patients undergo repair of asymptomatic AAA within 6 months after the coronary revascularization. METHODS: The authors performed a retrospective review of patients who underwent repair or scheduled repair of an asymptomatic AAA within 6 months after coronary artery bypass graft (CABG) between March 1988 and October 1993. RESULTS: There was no mortality in the group of patients (n = 14) who underwent repair of AAA simultaneously or within 14 days of coronary revascularization. In contrast, there was a significantly increased mortality rate of 3 of 9 (33%) in patients scheduled to undergo repair of the AAA more than 2 weeks after coronary revascularization (p < 0.05). All nonsurvivors died between 16 and 29 days after CABG, and died as a result of ruptured AAA. CONCLUSION: Elective AAA repair should be undertaken simultaneously or within 2 weeks of coronary artery revascularization because of an increased risk of postoperative AAA rupture seen after this time period. In addition, simultaneous or early postoperative AAA repair does not increase the overall operative risk.