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.     

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.     

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.     

Estimation of physiologic ability and surgical stress (E-PASS) as a predictor of immediate outcome after elective abdominal aortic aneurysm surgery

BACKGROUND: The Estimation of Physiologic Ability and Surgical Stress (E-PASS) score was designed on the premise that the balance between the patient's physiologic reserve capacity and the surgical stress inflicted at operation was important in the occurrence of postoperative complications. The aim of this study was to assess its value in predicting mortality and morbidity after open elective abdominal aortic aneurysm (AAA) repair. METHODS: E-PASS data items were collected prospectively in a group of 204 patients undergoing elective open AAA repair over a 6-year period. The operative morbidity and mortality rates were compared with the preoperative risk score (PRS), surgical stress score (SSS) and comprehensive risk score (CRS) of E-PASS. The group comprised 180 (88%) males and the median age was 73 (range 44 to 86) years. RESULTS: There were 13 (6%) deaths and 121 (59%) experienced a postoperative complication. As the PRS, SSS and CRS increased, the incidence of postoperative morbidity and mortality significantly increased (P < .0001). Overall mean CRS was .52 (+/-.27). Mean CRS in the groups of patients who survived and died were .49 (+/-.24) and .98 (+/-26), respectively. PRS, SSS, and CRS all had extremely good predictive power for both mortality and morbidity as demonstrated by high areas under the receiver operator curve (range .799 to .953). CRS also showed a strong statistically significant association with the severity of postoperative complication (P < .0001) and length of hospital stay (P < .0001). CONCLUSIONS: The E-PASS model appears to be a promising method of predicting death and the development of postoperative complications in patients undergoing elective open AAA surgery. It requires further validation in arterial surgery at different geographical locations.     

Intra-mucosal acidosis as a predictor of cardiac outcome following abdominal aortic aneurysm surgery.

OBJECTIVE: To assess if sigmoid ischaemia is a prognostic indicator of early and late post-operative cardiac morbidity and mortality. MATERIALS AND METHODS: Patients undergoing elective abdominal aortic aneurysm repair (AAAR) were included in the study. Demographic details and risk factors for heart disease were recorded. Sigmoid pHi was measured at the time of surgery using a silicone tonometer and perioperative morbidity and mortality were recorded in all patients. Seven years following surgery the patients and their general practitioners were contacted to determine the patient's health. RESULTS: Thirty-eight patients were included in the study. Within the follow-up period, 22 (58%) had died. Eight patients died of cardiac failure or myocardial infarction. The pHi in patients with cardiac related deaths [6.99 (6.84-7.10)] was significantly lower than those with non-cardiac related deaths [7.11 (7.04-7.21), p<0.05]. Similarly, patients who suffered acute cardiac events (within 30 days following AAA repair) had lower pHi [7.01 (6.88-7.12)] compared to those who did not [7.09 (6.90-7.19), p<0.05]. CONCLUSION: The results show that sigmoid ischaemia is more frequent amongst patients that develop cardiac events after AAAR and is associated with a worse long term outcome. This suggests that global hypoperfusion as a result of an under performing heart may be partly responsible for the sigmoid ischaemia in patients following AAAR. Therefore, low sigmoid pHi may predict an increased risk of cardiac complications in these patients.     

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.     

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.     

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.     

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.     

The influence of gender on outcome after ruptured abdominal aortic aneurysm

BACKGROUND: The influence of gender on the management of coronary artery disease is well documented, but few reports exist regarding the influence of gender on the management of peripheral arterial disease. OBJECTIVE: The purpose of this study was to examine the influence of gender on selection for and short-term and long-term outcomes of repair of ruptured abdominal aortic aneurysm (RAAA) in a regional vascular surgery unit. METHODS: Analysis of the prospectively gathered Lothian Surgical Audit database identified 692 patients (542 male and 150 female) admitted with RAAA between January 1, 1983, and December 31, 1995. Case notes were reviewed for patients who were admitted but not operated on. Operative mortality was defined as death within the same hospital admission. Long-term survival data were obtained from the General Register Office (GRO1 records) through record linkage by the Information and Statistics Division of the National Health Service of Scotland. RESULTS: A total of 542 men (78%; median age, 72 years; age range, 46-93 years) and 150 women (22%; median age, 74 years; age range, 55-93 years) were admitted with RAAA (P =.12; Mann-Whitney U test). There was no significant difference in perioperative mortality between men and women. Although women who were not operated on (median age, 81 years; age range, 68-93 years) were significantly (P =.005) older than men who were not operated on (median age, 77 years; age range, 54-93 years), for any given age group, women appeared less likely than men to be offered surgical repair. Long-term survival after successful repair was comparable for the genders. CONCLUSIONS: Gender has no influence on either short-term or long-term outcome for patients undergoing operative repair of RAAA. However, women are less likely to be selected for operation than their male counterparts.     

Cardiac troponin I predicts outcome after ruptured abdominal aortic aneurysm repair

BACKGROUND: Cardiac troponin I (cTnI) is a highly sensitive and specific marker for myocardial injury that predicts mortality in patients with acute coronary syndromes. This study examined the relationship between perioperative cTnI levels and clinical outcome in patients with ruptured abdominal aortic aneurysm (AAA). METHODS: Consecutive patients who underwent operative repair of a ruptured AAA over a 22-month interval and survived for more than 24 h were entered into a prospective observational cohort study. Levels of cTnI were measured immediately before, and at 24 and 48 h after surgery, and related to clinical outcome. RESULTS: Of 62 patients who underwent attempted operative repair of ruptured AAA, 50 (81 per cent) survived for more than 24 h and were included in this study. Twenty-three (46 per cent) of the 50 had a detectable cTnI level at one or more time points during the first 48 h. Of these, 11 patients had clinical or electrocardiographic evidence of an acute cardiac event and 12 did not; five patients in each of these two groups died. Of 27 patients with no increase in cTnI in the first 48 h, only three died (P = 0.031 and P = 0.043 respectively, relative to the groups with detectable cTnI). CONCLUSION: Approximately half of patients who survived repair of ruptured AAA for more than 24 h sustained a detectable myocardial injury within the first 48 h. A perioperative increase in the level of cTnI, with or without clinically apparent cardiac dysfunction, was associated with postoperative death.     

Short-term predictors and long-term outcome after ruptured abdominal aortic aneurysm repair

Few data exist in regard to long-term and functional outcome after ruptured abdominal aortic aneurysm (rAAA) repair. The present study provides such follow-up and defines the impact of variables used to grade resuscitation efforts [base deficit (BD) and core temperature (cT)]. One hundred forty-seven patients presenting with rAAA were retrospectively reviewed. Overall perioperative mortality was 35 per cent (51/147) and mean age was 72 years. Survival data were available for 99 per cent of patients with a mean and median follow-up of 45 months. Life table analysis revealed one-, 2-, and 5-year survival to be 81, 75, and 58 per cent, respectively. Eighty-three per cent of patients reported a quality of life equal to that of their preoperative status. Both initial cT (P = 0.02) and BD (P = 0.03) were significantly associated with perioperative mortality. Using a logistic regression model cT remained a significant factor (P = 0.006) associated with survival. Smoking, hypertension, diabetes, chronic obstructive pulmonary disease, mode of transportation, and surgeon's training were not significant. Despite the advanced age of the present cohort, acceptable perioperative mortality and long-term survival rates were attained. The majority of patients resumed a lifestyle comparable to that of their preoperative state; therefore, long-term longitudinal follow-up suggests that aggressive management with rapid correction of BD and cT results in excellent functional outcome.