Value of the Glasgow Aneurysm Score in predicting the immediate and long-term outcome after elective open repair of infrarenal abdominal aortic aneurysm

BACKGROUND: This study aimed to explore the value of the Glasgow Aneurysm Score in predicting the immediate and long-term outcome after elective open repair of abdominal aortic aneurysm (AAA). METHODS: Some 403 patients underwent elective open repair of an infrarenal AAA and were classified retrospectively according to the criteria of the Glasgow Aneurysm Score (risk score = (age in years) + (7 for myocardial disease) + (10 for cerebrovascular disease) + (14 for renal disease)). RESULTS: Fourteen patients (3.5 per cent) died after operation, 23 (5.7 per cent) had a myocardial infarction and six (1.5 per cent) had a stroke. One hundred and nine patients (27.0 per cent) experienced severe postoperative complications. The Glasgow Aneurysm Score was predictive of postoperative death (area under the receiver-operator characteristic curve (AUC) 0.80, 95 per cent confidence interval (c.i.) 0.71 to 0.90), severe postoperative complications (AUC 0.67, 95 per cent c.i. 0.61 to 0.73), myocardial infarction (AUC 0.72, 95 per cent c.i. 0.62 to 0.82), myocardial infarction-related postoperative death (AUC 0.78, 95 per cent c.i. 0.63 to 0.94) and stroke (AUC 0.84, 95 per cent c.i. 0.74 to 0.95). Univariate analysis showed that this risk index was also predictive of long-term survival. CONCLUSION: The Glasgow Aneurysm Score is a good predictor of outcome after elective open repair of AAA. Its simplicity and accuracy make it useful for preoperative risk stratification.     

Glasgow Aneurysm Score in Patients Undergoing Elective Open Repair of Abdominal Aortic Aneurysm: A Finnvasc Study

OBJECTIVE: To use Finnvasc to determine whether the Glasgow Aneurysm Score predicts postoperative outcome after open repair of abdominal aortic aneurysm (AAA). DESIGN: Retrospective study. MATERIAL AND METHODS: The operative risk of 1911 patients undergoing open repair of AAA was retrospectively graded according to the Glasgow Aneurysm Score. RESULTS: At 30 days 100 (5%) patients had died and 21% had developed severe postoperative complications. Receiver operating characteristics (ROCs) curve analysis showed that the Glasgow Aneurysm Score was predictive of postoperative mortality (area under the curve (AUC): 0.668, p<0.0001), severe complications (AUC: 0.654, p<0.0001), cardiac complications (AUC: 0.689, p<0.0001) and intensive care unit stay >5 days (AUC: 0.634, p<0.0001). Patients scoring >76 had significantly higher mortality (9% vs. 3%, p<0.0001), severe (31% vs. 15%, p<0.0001) and cardiac complications (12% vs. 4%, p<0.0001) and intensive care unit stay >5 days (12% vs. 6%, p<0.0001). CONCLUSIONS: The Glasgow Aneurysm Score is a rather good predictor of immediate postoperative mortality and morbidity after elective open repair of AAA.     

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.     

Outcome after emergency repair of symptomatic, unruptured abdominal aortic aneurysm: results in 42 patients and review of the literature

OBJECTIVE: To evaluate the results of our experience in the management of patients with symptomatic, unruptured abdominal aortic aneurysm (AAA), to identify the predictors of immediate outcome and to define the worldwide postoperative mortality rate through a review of previous studies on this condition. PATIENTS AND METHODS: Forty-two patients underwent emergency repair for symptomatic, unruptured AAA. RESULTS: Four patients (9.5%) died during the in-hospital stay, three of myocardial infarction and one of multiorgan failure. Only preoperative creatinine was predictive of postoperative death (p = 0.04, OR 1.31). The Glasgow Aneurysm Score tended to be predictive of postoperative death (p = 0.06), survivors having had a median score of 76.0 (IQR, 75.5-82.1) and patients who died of 87.1 (78.9-89.9). The receiver operating characteristic (ROC) curve analysis showed that the Glasgow Aneurysm Score had an area under the curve of 0.789 (95% CI: 0.596-0.983, SE: 0.099, p = 0.06). Its best cut-off value in predicting postoperative death was 85 (specificity 86.8%, sensitivity 75.0%). The postoperative mortality rate among patients with a Glasgow Aneurysm Score <85 was 2.9%, whereas it was 37.5% among those with a score >85 (p = 0.003). A review of the results of previous studies on this condition, including also the present series, showed that 207 out of 1312 patients (15.8%) died after emergency operation for symptomatic, unruptured AAA. CONCLUSION: Emergency open repair of symptomatic, unruptured AAA is associated with a high risk of postoperative death. The results of this study suggest that a rather good postoperative survival rate can be expected in patients with a Glasgow Aneurysm Score <85. A watchful waiting policy or, alternatively, emergency endovascular repair should be advocated in patients with a higher score.     

Glasgow aneurysm score predicts the outcome after emergency open repair of symptomatic, unruptured abdominal aortic aneurysms.

OBJECTIVE: To determine the predictor factors of in-hospital postoperative mortality in patients presenting with symptomatic but not ruptured abdominal aortic aneurysm (AAA) at our institution. PATIENTS AND METHODS: Forty-two patients who underwent urgent open repair for symptomatic, non-ruptured AAA were evaluated retrospectively. RESULTS: Five patients (11.9%) died during the in-hospital stay. History of coronary artery disease (p=0.014), cerebrovascular diseases (p=0.015), renal failure according to Glasgow Aneurysm Score (GAS) criteria (p=0.001), serum creatinine concentration (p=0.026), and the GAS (p=0.008) were predictive of postoperative death. The ROC curve analysis showed that the Glasgow Aneurysm Score had an area under the curve of 0.870 (95%C.I. 0.71-1, S.E. 0.08, p=0.008), and its best cut-off value in predicting postoperative death was 90.0 (specificity 89.2%, sensitivity 80.0%). The postoperative mortality rate of patients with a Glasgow Aneurysm Score below 90 was 2.9%, whereas it was 50% for those with a score >or=90 (p=0.003, O.R. 33.0). CONCLUSION: This study shows that the Glasgow Aneurysm Score is a good predictor of postoperative mortality and morbidity after urgent repair of symptomatic, non-ruptured AAA and can be useful in identifying those patients whose operative risk is prohibitive. Its simplicity makes it a clinically important tool, particularly, in the emergency setting. Patients having a score less than 90 can safely undergo urgent open repair. Thorough evaluation and improvement of preoperative status followed preferably by an endovascular repair is indicated for those with a score >or=90.     

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.     

Outcome after emergency repair of symptomatic,unruptured abdominal aortic aneurysm: Results in 42 patients and review of the literature

Objective To evaluate the results of our experience in the management of patients with symptomatic, unruptured abdominal aortic aneurysm (AAA), to identify the predictors of immediate outcome and to define the worldwide postoperative mortality rate through a review of previous studies on this condition.

Patients and methods Forty-two patients underwent emergency repair for symptomatic, unruptured AAA.

Results Four patients (9.5%) died during the in-hospital stay, three of myocardial infarction and one of multiorgan failure. Only preoperative creatinine was predictive of postoperative death (p=0.04, OR 1.31). The Glasgow Aneurysm Score tended to be predictive of postoperative death (p=0.06), survivors having had a median score of 76.0 (IQR, 75.5–82.1) and patients who died of 87.1 (78.9–89.9). The receiver operating characteristic (ROC) curve analysis showed that the Glasgow Aneurysm Score had an area under the curve of 0.789 (95% CI: 0.596–0.983, SE: 0.099, p=0.06). Its best cut-off value in predicting postoperative death was 85 (specificity 86.8%, sensitivity 75.0%). The postoperative mortality rate among patients with a Glasgow Aneurysm Score <85 was 2.9%, whereas it was 37.5% among those with a score >85 (p=0.003). A review of the results of previous studies on this condition, including also the present series, showed that 207 out of 1312 patients (15.8%) died after emergency operation for symptomatic, unruptured AAA.

Conclusion Emergency open repair of symptomatic, unruptured AAA is associated with a high risk of postoperative death. The results of this study suggest that a rather good postoperative survival rate can be expected in patients with a Glasgow Aneurysm Score <85. A watchful waiting policy or, alternatively, emergency endovascular repair should be advocated in patients with a higher score.     

The role of coronary artery disease in complications of abdominal aortic aneurysm surgery

Coronary artery disease (CAD) is a major cause of morbidity and mortality after elective surgical repair of abdominal aortic aneurysm (AAA). The aim of this study was to determine the relationship between the extent of CAD observed in coronary angiograms (more than 50% stenosis) and the frequency of postoperative myocardial ischemic complications in a consecutive series of 84 patients who underwent elective AAA repair. Ninety-four percent of the patients with clinical evidence of CAD had significant disease as observed in coronary angiograms and eight patients had left main CAD. Seventy-two patients underwent AAA repair with a mortality rate of 1.4%; five patients had preliminary myocardial revascularization, and AAA surgery was not recommended for four patients because of severe cardiac disease. Postoperative myocardial ischemic complications occurred in 13.4% of the patients who had undergone surgery--almost exclusively in patients with clinical evidence of CAD. Both myocardial ischemia and preoperative intervention were more frequent in patients with double- or triple-vessel disease than in patients with less extensive disease. Patients with symptoms and with double- or triple-vessel CAD have a high risk of developing myocardial ischemia after AAA surgery. Preliminary myocardial revascularization may be beneficial in this group of patients.     

Preoperative risk stratification in patients undergoing elective infrarenal aortic aneurysm surgery: evaluation of five risk scoring methods.

OBJECTIVE: To evaluate five risk scoring methods in predicting the immediate postoperative outcome after elective open repair of abdominal aortic aneurysm (AAA). DESIGN: Retrospective evaluation of the Eagle score, Glasgow aneurysm score, Leiden score, modified Leiden score and Vanzetto score in a consecutive series of patients. PATIENTS: Two hundred and eighty-six consecutive patients undergoing elective infrarenal aortic aneurysm repair. RESULTS: Nine patients (3.1%) died in hospital and another 35 (12%) experienced severe postoperative complications. For the Glasgow aneurysm score, Leiden score, modified Leiden score and Vanzetto score receiver operating characteristics (ROC) curve analysis for prediction of in-hospital mortality showed area under the curve (AUC) of 0.749 (p=0.01), 0.777 (p=0.008), 0.788 (p=0.006) and 0.794 (p=0.005), respectively. The Eagle risk score was less accurate for predicting in-hospital mortality. The risk-scoring systems did not perform well in predicting post-operative complications, but multivariate analysis showed that the modified Leiden score was an independent predictor of postoperative complications. CONCLUSION: All scoring systems predict, with reasonable accuracy, the risk of in-hospital death in patients undergoing elective open repair of AAA, whereas the accuracy in predicting severe postoperative complications is less.     

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.     

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.     

Peroperative factors influencing the outcome of elective abdominal aorta aneurysm repair.

PURPOSE: To identify perioperative variables which may influence mortality of elective abdominal aneurysm repair (AAA). METHOD: prospective study of patients undergoing elective AAA repair between 1986 and 1997. RESULTS: Four hundred and seventy patients (438 men, 32 females) with a mean age of 69.4+/-13 years and aneurysms with a diameter of 60+/-3 mm were operated on with a 1-month mortality rate of 5.3%. Multivariate analysis identified the following independent risk factors for mortality: age >70 (p<0.0001), a past history of myocardial infarction (p<0.0001), preoperative renal insufficiency (p<0.0001), reoperation (p<0.0001), colonic necrosis (p<0.0001), and severe postoperative medical complications (p<0.0001). CONCLUSION: Intra- and postoperative events affect the outcome of AAA repair, independently of preoperative factors, and should be described when presenting the results of AAA repair.     

External validation of Vascular Study Group of New England risk predictive model of mortality after elective abdominal aorta aneurysm repair in the Vascular Quality Initiative and comparison against established models

Objective

The purpose of this study is to externally validate a recently reported Vascular Study Group of New England (VSGNE) risk predictive model of postoperative mortality after elective abdominal aortic aneurysm (AAA) repair and to compare its predictive ability across different patients' risk categories and against the established risk predictive models using the Vascular Quality Initiative (VQI) AAA sample.

腹主动脉瘤患者术后近期死亡和严重并发症

目的了解肾动脉下腹主动脉瘤患者术后近期病死率和并发症发生率,并分析其原因. 方法选择自1988年1月～200 0年12月,在我院行手术治疗的肾动脉下腹主动脉瘤186例,统计术后近期病死率和并发症发生率,分析术前心、肺、肾功能,年龄和手术因素与严重并发症和死亡的关系. 结果择期手术术后近期病死率5.0%,动脉瘤破裂急诊手术57.1 %.择期手术术后近期严重并发症发生率18.4%,其中心血管并发症10.6%,呼吸道并发症1 1.2%,急性肾功能衰竭2.8%,脑血管意外1.1%,肝功能损害1.1%.心血管并发症与术前冠心病明显相关(χ2=19.737,P＜0.01)而与高血压无关(χ2=1.870,P ＞0.05).术前肺功能异常、吸烟史和血氧分压＜80 mmHg与肺部感染有关(χ2=4. 051、5.885和5.162,P＜0.05)而与成人呼吸窘迫综合征无关(χ2=0.127、0 .916和1.067,P＞0.05).术前肾功能状况与急性肾功能衰竭无关(χ2=0.404 ,P＞0.05).70岁以上或手术时间超过5 h,术后严重并发症(χ2=16.119和10 .163,P＜0.01)和死亡(χ2=7.045和12.145,P＜0.01)的发生率明显增加. 结论多系统器官功能衰竭是导致腹主动脉瘤术后近期死亡的主要原因.术后严重并发症以心肺疾病居多.术前心、肺功能,年龄和手术因素与术后严重并发症和死亡密切相关.     

Prognostic scoring in ruptured abdominal aortic aneurysm: a prospective evaluation

BACKGROUND: Prospective validation of prognostic scoring systems for ruptured abdominal aortic aneurysm (AAA) is lacking. This study assesses the validity of three established risk scores and a new prognostic index. METHOD: Patients admitted with ruptured AAA during a 26-month period (August 2002-December 2004) were recruited prospectively. The Glasgow Aneurysm Score (GAS), Hardman Index, Physiological and Operative Severity Score for enUmeration of Mortality and Morbidity (POSSUM) scores, and the Edinburgh Ruptured Aneurysm Score (ERAS) were recorded and related to outcome. RESULTS: During the study period, 111 patients were admitted with ruptured AAA. Of these, 84 (76%) underwent attempted operative repair and were included in the study; 37 (44%) died after operation. The GAS, Hardman Index, and the ERAS were statistically related to mortality. However, analysis by receiver-operator characteristic curve revealed the ERAS to have an area under the curve (AUC) of 0.72 (95% confidence interval [CI], 0.61-0.83). The vascular (V)-POSSUM and ruptured AAA (RAAA)-POSSUM models had an AUC of 0.70 (95% CI, 0.59-0.82). The Hardman Index and GAS had an AUC of 0.69 (95% CI, 0.57-0.80) and 0.64 (95% CI, 0.52-0.76), respectively. Although the V-POSSUM equation predicted mortality effectively (P = .086), the RAAA-POSSUM derivative demonstrated a significant lack of fit (P = .009). CONCLUSION: Prospective validation shows that the Hardman Index, GAS, and V-POSSUM and RAAA-POSSUM scores do not perform well as predictors for death after ruptured AAA. The ERAS accurately stratifies perioperative risk but requires further validation.     

A prospective study of subclinical myocardial damage in endovascular versus open repair of infrarenal abdominal aortic aneurysms

BACKGROUND: Endovascular repair of abdominal aortic aneurysms (AAAs) is considered to be less invasive and better tolerated by the cardiovascular system than open repair. Our aim was to assess the true incidence of perioperative myocardial damage associated with endovascular vs open infrarenal AAA repair. METHODS: Between July 1999 and June 2001, preoperative and postoperative serum troponin T (TnT) levels were measured in all patients presenting for elective AAA repair at Royal Prince Alfred Hospital. The incidence of myocardial damage was recorded on the basis of standard clinical, biochemical, and electrocardiographic changes or a subclinical increase of 50% or more in serum TnT. Patients were excluded if the TnT increase was associated with a significant increase of serum creatinine (> or =50%) with no other evidence of myocardial ischemia. The differences between the two groups were analyzed with the chi 2 test and odds ratios. RESULTS: A total of 35 open and 112 endovascular AAA repairs were included in the study. There was no significant difference in age, sex, preoperative serum creatinine, or preoperative serum TnT between the two treatment groups. Seventeen patients had biochemical evidence of myocardial damage, which was clinically obvious in only one patient. Even though the incidence of previous myocardial infarction was significantly higher in patients undergoing endovascular repair (41%) than open repair (22%; P < .05), the overall incidence of myocardial damage (clinical or subclinical) was significantly higher in the open group compared with the endovascular group (8 [25%] of 32 vs 9 [8%] of 109, respectively; odds ratio, 3.7; 95% confidence interval, 1.28-10.49; P < .02). CONCLUSIONS: There is a previously underestimated incidence of subclinical myocardial damage associated with surgery for infrarenal AAA which is lower after endovascular than open repair.     

Glasgow Aneurysm Score predicts survival after endovascular stenting of abdominal aortic aneurysm in patients from the EUROSTAR registry

BACKGROUND: The aim of the present study was to evaluate the efficacy of the Glasgow Aneurysm Score (GAS) in predicting the survival of 5498 patients who underwent endovascular repair (EVAR) of an abdominal aortic aneurysm (AAA) and were enrolled in the EUROpean collaborators on Stent-graft Techniques for abdominal aortic Aneurysm Repair (EUROSTAR) Registry between October 1996 and March 2005. METHODS: The GAS was calculated in patients who underwent EVAR and was correlated to outcome measurements. RESULTS: The median GAS was 78.8 (interquartile range 71.9-86.4, mean 79.2). Tertile 30-day mortality rates were 1.1 per cent for patients with a GAS less than 74.4, 2.1 per cent for those with a score between 74.4 and 83.6, and 5.3 per cent for patients with a score over 83.6 (P < 0.001). Multivariate analysis showed that GAS was an independent predictor of postoperative death (P < 0.001). The receiver-operator characteristic curve showed that the GAS had an area under the curve of 0.70 (95 per cent confidence interval 0.66 to 0.74; s.e. 0.02; P < 0.001) for predicting immediate postoperative death. At its best cut-off value of 86.6, it had a sensitivity of 56.1 per cent, specificity 76.2 per cent and accuracy 75.6 per cent. Multivariable analysis showed that overall survival was significantly different among the tertiles of the GAS (P < 0.001). CONCLUSION: The GAS was effective in predicting outcome after EVAR. Because its efficacy has also been shown in patients undergoing open repair of AAA, it can be used to aid decisions about treatment in all patients with an AAA.     

Prediction of outcome after abdominal aortic aneurysm rupture

BACKGROUND: Most vascular surgeons practice a selective policy of operative intervention for patients with ruptured abdominal aortic aneurysm (AAA). The evidence on which to justify operative selection remains uncertain. This review examines the prediction of outcome after attempted open repair of ruptured AAA. METHODS: The Medline and EMBASE databases and Cochrane Database of Systematic Reviews were searched for clinical studies relating to the prediction of outcome after ruptured AAA. Reference lists of relevant articles were also reviewed. RESULTS: The last 20 years has seen >60 publications considering variables predictive of outcome after AAA rupture. Four predictive scoring systems are reported: Hardman Index, Glasgow Aneurysm Score, Physiological and Operative Severity Score for Enumeration of Mortality and Morbidity (POSSUM), and the Vancouver Scoring System. No scoring system has been shown to have consistent or absolute validity. Of the remaining data, there are no individual or combination of variables that can accurately and consistently predict outcome. CONCLUSIONS: Little robust evidence is available on which to base preoperative outcome prediction in patients with ruptured AAA. Experienced clinical judgement will remain of foremost importance in the selection of patients for ruptured AAA repair.     

Ruptured abdominal aortic aneurysm: Six-year follow-up results of a multicenter prospective study

Purpose: On the basis of a prospective analysis of 147 patients undergoing surgery for ruptured abdominal aortic aneurysm (AAA) and recorded in the Canadian Society for Vascular Surgery Aneurysm Registry, this study defines the early and 6-year actuarial survival rates and determines the predictive variables that are associated with survival.Methods: Ongoing follow-up of a cohort of patients was current at the time of analysis. To identify the preoperative, intraoperative, and postoperative variables that were associated with survival, statistical methods included chi-squared analysis, logistic regression analysis, Kaplan-Meier analysis, and Cox regression analysis.Results: The survival rate was 48.6% at 1 month, 34.7% ± 4.2% at 3 years, and 22.0% ± 4.0% at 6 years. When preoperative and intraoperative variables were considered and logistic regression analysis was used, the highest probability of early in-hospital survival was associated with preoperative creatinine levels of 1.3 mg/dl or less, intraoperative urine output of 200 ml or greater, and infrarenal clamp site. The highest probability of late survival, as calculated by the Cox proportional hazards method, was predicted by the patient's age and total urine output during the procedure. When all variables, including postoperative complications, were considered, late survival was highest if intraoperative urine output was 200 ml or greater and respiratory failure and myocardial infarction did not occur. For those patients with ruptured AAA who survived operation (i.e., greater than 1 month), the long-term survival rate was significantly lower than a comparable group undergoing repair of nonruptured AAA.Conclusions: Patients who survive repair of a ruptured AAA have a lower late survival rate than patients undergoing elective repair. When a patient is evaluated before operation, no combination of preoperative variables could identify those patients with little or no chance of survival; hence, the decision to repair a ruptured AAA should be made on clinical grounds. However, after surgery (when information on intraoperative and postoperative variables is also available), the results of this study provide a basis for the surgeon to use these prognostic variables to assist clinical judgment and guide discussions on prognosis with the family and to identify those patients who have such a low chance of early and late survival that further aggressive treatment may be futile. (J VASC SURG 1994;19:888-900.)     

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.