Ruptured abdominal aortic aneurysm: factors influencing operative mortality

Of fifty-eight consecutive patients surgically treated for aneurysm of the abdominal aorta, twenty were emergency cases following the rupture. Associated diseases were found in 85 per cent of patients; hypertension being the most common. Fifty per cent of patients were in shock on admission. The duration between rupture and operation was three hrs to two weeks with the average of 115.5 hrs. In six patients, the diagnosis of abdominal aortic aneurysm was known for over six months. The operative mortality rate in case of ruptured abdominal aortic aneurysm was 45 per cent. The most important determinants of survival were the incidence of shock on admission, the incidence of associated disease, the known duration of the aneurysm, and the time interval from rupture to admission. The intraoperative factors most influencing survival were the type of rupture, intraoperative hypotension, and total blood loss. Comparison of the mortality rate in elective surgery of abdominal aortic aneurysms (5.3 per cent) with that in ruptured aneurysms (45.0 per cent) suggests the necessity for early elective operations whenever abdominal aortic aneurysms are diagnosed.     

Ruptured abdominal aortic aneurysm. Treatment and review of eighty-seven patients

Between 1954 and 1973 at the Texas Heart Institute, eighty-seven patients underwent operation for resection of ruptured abdominal aortic aneurysms. Included in this series were eighty-one men and six women who ranged in age from forty-four to eighty-four years. Hospital mortality, including intra- and postoperative mortality (within thirty days of operation), was 21 per cent. Mortality for men was 19.8 per cent and for women, 33.3 per cent.The lower mortality indicates that abdominal aortic aneurysms should be excised electively. When rupture does occur, aggressive surgical treatment can produce gratifying results.     

The surgical experience and a one to sixteen year follow-up of 277 abdominal aortic aneurysms

Between 1960 and 1975, 277 patients with abdominal aortic aneurysms were operated on at the West Virginia University Medical Center. One hundred ninety-three aneurysms were intact lesions and eighty-four were ruptured. Operative mortality for elective resection was 8.8 per cent and for ruptured aneurysms 66.7 per cent. Mortality associated with ruptured abdominal aortic aneurysms was best related to shock and advanced age. Ninety-nine per cent of patients underwent long-term follow-up which ranged from thirteen months to thirteen years and four months (mean, 4 years and 9 months). At present 61 per cent of patients surviving elective resection and 50 per cent of those surviving operation for ruptured aneurysm are alive.     

Ruptured abdominal aortic aneurysm: Factors influencing operative mortality

Of fifty-eight consecutive patients surgically treated for aneurysm of the abdominal aorta, twenty were emergency cases following the rupture. Associated diseases were found in 85 per cent of patients; hypertension being the most common. Fifty per cent of patients were in shock on admission. The duration between rupture and operation was three hrs to two weeks with the average of 115.5 hrs. In six patients, the diagnosis of abdominal aortic aneurysm was known for over six months. The operative mortality rate in case of ruptured abdominal aortic aneurysm was 45 per cent. The most important determinants of survival were the incidence of shock on admission, the incidence of associated disease, the known duration of the aneurysm, and the time interval from rupture to admission. The intraoperative factors most influencing survival were the type of rupture, intraoperative hypotension, and total blood loss. Comparison of the mortality rate in elective surgery of abdominal aortic aneurysms (5.3 per cent) with that in ruptured aneurysms (45.0 per cent) suggests the necessity for early elective operations whenever abdominal aortic aneurysms are diagnosed. Presented at the Fifteenth Annual Meeting of the Japanese Association for Cardiovascular Surgery, Kanazawa, Japan, May 17–18, 1985.     

Aneurysm of the infrarenal abdominal aorta

Preoperative and postoperative treatment as well as standardisation of surgical techniques over the past 20 years have helped to bring about considerable reduction of operative mortality in cases of asymptomatic aortic aneurysm. Yet, with all improvement, rupture of aneurysm has continued to be associated with high rates of mortality. At the Department of Surgery of Cologne University, between 1963 and 1985, operations were performed on 681 patients for abdominal aortic aneurysm. Asymptomatic aneurysm were surgically removed from 41.7 per cent of them, while 27.5 per cent underwent surgery in symptomatic stages. Aneurysm had ruptured in 210 patients. Operative mortality accounted for 5.3 per cent of all asymptomatic patients. High mortality rates among patients with ruptured aortic aneurysms were attributable to preoperative shock. Only 16.3 per cent of patients survived in this group. The mortality rate among patients without shock amounted to 39.5 per cent.     

Ruptured abdominal aortic aneurysms in community practice: age and operative variables predict survival

Our objective is to determine if the mortality and functional outcome of patients with ruptured abdominal aortic aneurysms treated at community hospitals is more a function of patient factors and comorbidities or hospital system and surgeon-controlled variables. We used a retrospective review of all patients with infrarenal ruptured abdominal aortic aneurysms treated at three large community hospitals in Chicago from 1996 to 2005. There was an overall 58 per cent mortality rate. There was a statistically significant difference in the age of those who lived (69 +/- 9.8) and those who died (78 +/- 7.9, P = 0.0005). Mortality was found to increase with each increasing decade of life. None of the patients from age 50 to 60 died, whereas 44 per cent of the patients from 61 to 70, 65 per cent of those 71 to 80, 64 per cent of those 81 to 90, and 100 per cent of those older than 90 died. There was an increased hazard ratio of 10.9 times the risk of mortality once a patient became older than age 70 (P = 0.02). Intra-operative variables did influence survival: duration of surgery (lived 230 +/- 78 minutes, died 324 +/- 130 minutes, P = 0.006), intra-operative blood loss (lived 1894 +/- 1014 mL, died 5692 +/- 3018 mL, P = 0.00003), and blood transfusion (lived 6.7 +/- 2.8 units, died 10.5 +/- 3.7 units, P = 0.0006). Age and intra-operative factors play a major role in the survival or mortality of patients with ruptured abdominal aortic aneurysms. Short operative time combined with minimizing blood loss and transfusion requirements improve survival, especially in the elderly.     

Emergency operation in patients with symptomatic abdominal aortic aneurysms

To assess the need for routine preoperative computerized tomography scanning to discern patients with rupture among those presenting with acutely symptomatic abdominal aortic aneurysms, a retrospective review was performed. During a 5-year period, all patients presenting with symptomatic aneurysm underwent emergency operation without preoperative computerized tomography. The mortality rate was not significantly different among patients with symptomatic, intact aneurysms undergoing emergency operation (3 percent) and those without symptoms having elective operation (5 percent). The mortality rate of patients with ruptured aneurysms was 68 percent. We concluded that the addition of preoperative computerized tomography to the clinical evaluation would not have improved these results. Furthermore, since it is expensive and delays emergency operation in patients with ruptured aneurysms, computerized tomography seems rarely indicated in symptomatic patients with obvious aneurysms.     

Surgical treatment of the aortic aneursysm

For 93 cases of thoracic and 118 cases of abdominal aneurysms, the over-all operative mortality rate was 24.7 per cent and 9.3 per cent, respectively. Although the over-all operative mortality rate for 37 patients with aneurysms of the ascending aorta or aortic arch had been 40.5 per cent, recent advances in surgical technique led to a higher survival rate so that since 1975 no death occurred among 14 consecutive surgery cases. Cardiopulmonary bypass with or without selective perfusion of the carotid arteries or temporary external bypass procedures were employed in these 14 cases. The over-all operative mortality rate for 56 patients with aneurysms of the descending thoracic aorta was 14.3 per cent. Temporary external bypass prodedures were employed in 49 cases. The operative mortality rate for 99 patients with unruptured abdominal aneurysms was five per cent, and that for 19 patients with ruptured aneurysms was 31.5 per cent.     

Surgical treatment of the aortic aneurysm

For 93 cases of thoracic and 118 cases of abdominal aneurysms, the over-all operative mortality rate was 24.7 per cent and 9.3 per cent, respectively. Although the over-all operative mortality rate for 37 patients with aneurysms of the ascending aorta or aortic arch had been 40.5 per cent, recent advances in surgical technique led to a higher survival rate so that since 1975 no death occurred among 14 consecutive surgery cases. Cardiopulmonary bypass with or without selective perfusion of the carotid arteries or temporary external bypass procedures were employed in these 14 cases. The over-all operative mortality rate for 56 patients with aneurysms of the descending thoracic aorta was 14.3 per cent. Temporary external bypass procedures were employed in 49 cases. The operative mortality rate for 99 patients with unruptured abdominal aneurysms was five per cent, and that for 19 patients with ruptured aneurysms was 31.5 per cent.     

Ruptured abdominal aortic aneurysms: a study of incidence and mortality

The incidence of ruptured abdominal aortic aneurysms (AAA) during 1980 in the Stockholm county and the clinical fate of the patients were evaluated. Eighty-eight patients with ruptured AAA were found, an incidence of 0.06 per thousand. The overall mortality was 94 per cent. Sixty-four patients reached hospital, twenty-three received a correct diagnosis; thirteen were operated upon and five survived. Autopsy or operation revealed that most ruptures were retroperitoneal (88 per cent) and that only two aneurysms (2 per cent) extended above the renal arteries. It is concluded that the high mortality rate following rupture is more dependent upon failure to operate than on operative mortality.     

Abdominal aortic aneurysms: should they all be resected?

A retrospective study has been carried out on 124 consecutive patients with abdominal aortic aneurysms admitted during the period 1960-74. The mortality rate after emergency operation was 56 per cent and after elective operation 15 per cent. As in other vascular centres during these years the mortality rate has decreased among electively operated patients. We have tried to answer two questions: which patients without signs of rupture should undergo operation and which patients with a ruptured aneurysm should not be operated upon?     

Infrarenal aortic aneurysms. Asymptomatic versus symptomatic

Between 1978 and 1983, 103 patients underwent operations for infrarenal abdominal aortic aneurysms (AAA). Fifty-seven patients (group I) had elective procedures without a death and with a morbidity of 19 per cent. Thirty-three patients (group II) had symptomatic but nonruptured AAA, while 13 patients (group III) had ruptured AAA. In group II, the mortality was 6 per cent and in group III, 37 per cent, while the morbidity was 33 and 100 per cent, respectively. There was no morbidity or mortality from pulmonary emboli, as all patients had prophylactic inferior vena cava interruption at the time of operation for their AAA. These results substantiate the necessity for early and aggressive treatment in patients with AAA, as the mortality and morbidity, once symptoms develop, remain prohibitive.     

Impact of vascular surgery on community mortality from ruptured aortic aneurysms

The workload of aortic surgery in a district increased fourfold over 10 years as the incidence of aneurysm rupture rose from 7 to 17/100,000. Of 260 patients with ruptured aneurysms 101 reached hospital alive (38 per cent) of which 52 (52 per cent) survived, an overall survival rate of 19.8 per cent. Despite increasing experience, mortality after emergency surgery did not improve, suggesting outcome was largely determined by the patient's condition and age. Only 5 of 90 patients aged over 75 survived aortic rupture at home. In consequence overall community mortality did not improve in the period studied. Survival after elective surgery was 95 per cent, suggesting that efforts to improve survival should be directed towards identifying and treating the disease before rupture occurs. The commonly stated figure of 50 per cent survival for ruptured aortic aneurysms is an overestimate, due to neglect of patients dying at home.     

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.     

Factors that affect the mortality in patients receiving emergency surgery for ruptured abdominal aortic aneurysms

This retrospective study was performed to identify the perioperative factors affecting the mortality rate in 28 patients, who had received emergency surgery for ruptured abdominal aortic aneurysms from January, 2005 to June, 2008. Five (17.9%) of these 28 patients died of massive bleeding, sepsis, or multiple organ failure during or within 11 days after surgery. Various factors which might influence the outcomes were compared between the survivors and non-survivors. Preoperative hypotension defined as a systolic blood pressure < or = 80 mmHg associated with hemorrhagic shock was the only significant factor affecting the mortality. There were no significant differences in age, gender, the time from the admittance to the hospital to aortic cross clamping, duration of surgery, and the amount of blood products transfused and intraoperative blood loss, between the two groups. Of great importance is that preoperative hypotension should be corrected before the onset of hemodynamic deterioration.     

Replacement of the abdominal aorta with a sutureless intraluminal ringed prosthesis

To evaluate our experience with sutureless intraluminal ringed grafts in the abdominal aorta, we reviewed all patients who were managed with this device from 1980 to 1987. Thirty-one patients were identified with a mean follow-up time of 41 months. Three patients had suprarenal aneurysms and four had ruptured abdominal aneurysms. Average tube graft insertion time was 17 minutes and required 0.9 units of transfused blood. There were two postoperative deaths (6 percent), both secondary to myocardial infarction. None of the patients with ruptured or suprarenal aneurysms died. No patients had permanent renal or neurologic deficits, and no instances of postoperative bleeding, wound infection, pseudoaneurysm formation, or graft migration were encountered. The sutureless intraluminal graft can be implanted easily and quickly and is safe for use in the abdominal aorta. It is particularly helpful in the management of suprarenal or ruptured abdominal aneurysms, in which speed is important, and in effecting technically difficult anastomoses to friable aortic tissue.     

Randomized, multicentre, double-blind, placebo-controlled trial of the use of aprotinin in the repair of ruptured abdominal aortic aneurysm. On behalf of the Joint Vascular Research Group

BACKGROUND: The use of aprotinin in cardiac surgery reduces blood transfusion requirements. The aim of this trial was to see whether the same benefit applies in the repair of ruptured abdominal aortic aneurysm (AAA). METHODS: In this prospective, randomized trial, nine centres with local ethics committee approval recruited 77 patients with a ruptured AAA. A bolus of aprotinin 2 x 106 units, followed by an infusion of 0.5 x 106 units every 30 min, was administered to 38 patients, and 39 received a placebo infusion. The quantity of blood products transfused during surgery and in the first 12 h after operation was noted, along with the incidence of complications, mortality rates and length of hospital stay. RESULTS: Seventeen of the 38 patients who received aprotinin and 17 of the 39 given placebo died within 30 days (overall mortality rate 44 per cent). The median amount of blood given to the aprotinin group after operation was 1 (range 0-14) unit, while for the placebo group it was 3 (range 0-13) units (P = 0.02). However, the difference in the total number of units of blood transfused did not reach significance (10 (range 2-29) versus 14 (range 4-38) units respectively). CONCLUSION: The use of high-dose aprotinin during the repair of a ruptured AAA reduced blood transfusion requirements in the first 12 h after operation, but had no significant effect on the overall blood transfusion requirement.     

Twelve-year experience of the management of ruptured abdominal aortic aneurysm

Background The operative mortality rate for elective repair of asymptomatic abdominal aortic aneurysm (AAA) is falling but the fate of patients with ruptured AAA may have changed little over the past decade. Methods This study was an analysis of a prospectively gathered computerized database. Results In the 12 years to 31 December 1994, 1144 patients underwent (attempted) repair of AAA. In 514 patients (44·9 per cent) who had an operation for ruptured AAA there was no significant change in the mean age, male: female ratio (418:96), or operative mortality rate (35·0 per cent) over the interval of the study. Forty-seven patients died before reaching the operating theatre, giving an ‘intention to operate’ mortality rate of 405 per cent. A further 68 patients (10·8 per cent of all patients who presented with a ruptured AAA) were not offered operation because of poor medical condition (n = 34) or extreme age (n = 34); three patients refused operation. A greater proportion of patients had surgery between 1989 and 1994 (276 of 323, 85·4 per cent) than between 1983 and 1988 (238 of 309, 77·0 per cent) (P <0·01, X² test). Conclusion The proportion of aneurysms operated on for rupture in this unit remains high (almost 50 per cent). The results of surgery for ruptured AAA have not improved in the past 12 years.     

The mortality of abdominal aortic aneurysm.

During a five year period 153 patients presented with abdominal aortic aneurysms and 135 received grafts. The mortality was 4.2% (3 of 71) for elective cases, 16.7% (2 of 12) for acute cases (the preoperative diagnosis of rupture found to be incorrect) and 55.8% (29 of 52) for patients with ruptured aneurysms. For patients with ruptured aneurysms there was a trend towards larger amounts of blood and colloid infusion in patients who died compared with those who survived, but there was no statistically significant difference either for the amount transfused, or for age, distance of referral, preoperative blood pressure, operating theatre time, or seniority of operating surgeon, between the two groups. It is possible that increased attention to cardiac and renal disease might reduce mortality following elective surgery. Measures to reduce the high mortality from ruptured aneurysm must be early detection and treatment of intact aneurysms, rapid diagnosis of rupture and expeditious surgery with minimal blood loss and the accurate exclusion of rupture in acute cases to achieve the same mortality as elective surgery.     

Age-standardized incidence of ruptured aortic aneurysm in a defined Swedish population between 1952 and 1988: mortality rate and operative results.

The incidence and mortality rate of ruptured aortic aneurysm in a defined and stable Swedish population was determined for the period 1952-1988. The annual rupture rate of abdominal aneurysm rose significantly from 0.9 per 100,000 inhabitants in the 1950s to 6.9 in the 1980s. After standardization for age, the mortality rate increased between 1960 and 1988 by 2.4 per cent annually (95 per cent confidence interval 1.2-3.6 per cent, P = 0.0004). Comparable figures from the UK during the 1980s have been reported to be two to three times higher. The mortality rate of ruptured thoracic aneurysm in the Swedish population did not increase when adjusted for age. In the 1980s the overall mortality rate of ruptured abdominal aneurysm was 85 per cent. Death occurred outside surgical clinics in 52 per cent of cases; 37 per cent of the total number of patients with ruptured aneurysm reached the operating table but only 30 per cent underwent aortic reconstruction. Patients treated by vascular surgeons had lower blood loss and transfusion needs, shorter aortic clamp time and operation time, and lower mortality rate than patients treated by non-specialized general surgeons. Specialized vascular surgeons also completed the reconstruction, and used straight grafts, in a higher proportion of cases than general surgeons.