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.     

Quality of life after repair of ruptured abdominal aortic aneurysm.

BACKGROUND: Ruptured abdominal aortic aneurysm (AAA) continues to be associated with high operative mortality. Though survivors can expect to return to a normal life expectancy, their postoperative health related quality of life (HRQoL) remains uncertain. This review examines HRQoL following operative repair of ruptured AAA. METHODS: PreMedline, Medline and Embase databases were searched for clinical studies relating to quality of life following repair of ruptured AAA. Reference lists of relevant papers were also reviewed. RESULTS: Fourteen retrospective-observational studies of postoperative quality of life following repair of ruptured AAA were identified. Both validated and non-validated tools for generic HRQoL assessment were used. All but one study showed no significant difference in overall HRQoL following ruptured AAA repair when compared to both the normal age-adjusted population and patients undergoing elective repair of intact AAA. However, survivors of ruptured AAA did exhibit significant reductions in the isolated domains of physical function, social behaviour and general well-being. CONCLUSIONS: There are few studies of HRQoL following repair of ruptured AAA. These reports are retrospective, have small sample sizes and use generic instruments for HRQoL assessment. The findings suggest that survivors of ruptured AAA may attain a similar functional outcome to patients undergoing elective AAA repair and the age-matched healthy population. However, these results must be interpreted with caution and further prospective study is required.     

Epidemiology of surgically treated abdominal aortic aneurysms in the United States, 1988 to 2000

Abdominal aortic aneurysm (AAA) repair is a complex procedure about which little information exists regarding trends in surgical practice in the United States. This study was undertaken to define benchmark data regarding performance and outcomes of conventional AAA repair that might be used in comparisons with endovascular AAA repair data. Patients undergoing repair of intact (n = 87,728) or ruptured (n = 16,295) AAAs in the Nationwide Inpatient Sample (NIS) for 1988 to 2000 were studied. The NIS represents a 20% stratified random sample of all discharges from US hospitals. Unadjusted and case mix-adjusted analyses of in-hospital mortality and length of stay were performed. The overall frequency of intact AAA repair remained relatively stable during the study period, ranging from 18.1 to 16.3 operations/100,000 adults between 1988 and 2000, respectively. The operative mortality rate for intact AAA repair decreased significantly (p < .001) from 6.5% in 1988 to 4.3% in 2000. Length of stay following intact AAA repair also declined significantly (p < .001) from a median of 11 days in 1988 (interquartile range [IQR] 9-15 days) to 7 days in 2000 (IQR 5-10 days). The incidence of ruptured AAA repair decreased significantly (p < .001) from 4.2 to 2.6 operations/100,000 adults between 1988 and 2000, respectively. Mortality for ruptured AAA repair, averaging 45.6%, did not decrease significantly during the study period. Intact AAA repair by conventional means has become increasingly safe, with decreased operative mortality and shorter hospital stays. Ruptured AAA repair by conventional means has not become safer but has decreased in incidence, suggesting possible reductions in risk factors contributing to rupture, coupled with more timely intact AAA repairs.     

A randomised trial of endovascular and open surgery for ruptured abdominal aortic aneurysm - results of a pilot study and lessons learned for future studies.

INTRODUCTION: EVAR has the potential to improve outcome after ruptured abdominal aortic aneurysm (AAA). Published series have been based upon selected populations. METHODS: An interim analysis of a single centre prospective randomised controlled trial comparing endovascular aneurysm repair (EVAR) with open aneurysm repair (OAR) in patients with ruptured AAA was performed. Patients who had a ruptured AAA and who were considered fit for open repair were randomised to EVAR or OAR after consent had been obtained. Those in the EVAR group had pre-operative spiral computed tomographic angiography (CTA). The primary endpoint was operative (30-day) mortality and secondary endpoints were moderate or severe operative complications, hospital stay and time between diagnosis and operation. A power study calculation required 100 patients to be recruited. RESULTS: Between September 2002 and December 2004, 103 patients were admitted with suspected ruptured AAA. Only 32 patients were recruited to the study. Of these, four patients died before receiving surgical treatment. On an intention to treat basis the 30-day mortality rate was 53% in the EVAR group and 53% in the OAR group. Moderate or severe operative complications occurred in 77% in the EVAR group and in 80% in the OAR group. Median total hospital stay in the EVAR group was 10 days (inter-quartile range 6-28) and 12 days (4-52) in the OAR group. Median time between diagnosis and operation was 75 minutes (64-126) in the EVAR group and 100 minutes (48-138) in the OAR group. CONCLUSIONS: Despite the relative high operative mortality in the EVAR group, these preliminary results show that it is possible to recruit patients to a randomised trial of OAR and EVAR in patients with ruptured AAA. CT scanning does not delay treatment.     

Impact of chronic obstructive pulmonary disease on elective and emergency abdominal aortic aneurysm repair

OBJECTIVE: Chronic obstructive pulmonary disease (COPD) is associated with abdominal aortic aneurysm (AAA) expansion and is considered by some to be a relative contraindication to conventional aortic surgery. This study was undertaken to determine if COPD increases operative death, morbidity, intensive care unit (ICU) length of stay (LOS), and hospital LOS, after AAA repair. METHODS: Data from national administrative records supplemented with laboratory data previously obtained for a system-wide study were analyzed in a retrospective review of 1053 consecutive patients (264 with and 789 without COPD) undergoing operation for intact or ruptured AAAs in Veterans Administration Hospitals from 1997 to 1998. Bivariate comparisons and multivariate regression were used to evaluate the impact of COPD on the number of days of ventilation, ICU LOS, total hospital LOS, and death, while controlling for other known risk factors, including acute myocardial infarction, renal failure, and age. RESULTS: The mortality rate in elective aneurysm patients did not differ (P =.99) between patients with (3.7%) or without COPD (3.7%). However, elective AAA repair was associated with longer hospital LOS (14.4 vs 12.3 days, P =.01), longer ICU LOS (6.5 vs 5.4 days, P =.01), and a higher incidence of requiring 96 hours or more ventilation (6.9% vs 3.6%, P =.02) in patients with COPD. Ruptured AAA affected 4.9% of patients and was strongly associated with COPD (P =.02); however, COPD did not result in a statistically significant increase in death (P =.25). CONCLUSIONS: Although COPD does not appear to increase operative death, it is associated with an increased risk of rupture. Elective repair of AAA should not be deferred in patients with COPD despite their higher LOSs and need for postoperative ventilation.     

To what extent has endovascular aneurysm repair influenced abdominal aortic aneurysm management in the state of Illinois?

PURPOSE: This study was performed using population-based data to determine the changing trends in the techniques for abdominal aortic aneurysm (AAA) repair in the state of Illinois during the past 9 years and to examine the extent to which endovascular aneurysm repair (EVAR) has influenced overall AAA management. METHODS: All records of patients who underwent AAA repair (1995 to 2003 inclusive) were retrieved from the Illinois Hospital Association COMPdata database. The outcome as determined by in-hospital mortality was analyzed according to intervention type (open vs EVAR) and indication (elective repair vs ruptured AAA). Data were stratified by age, gender, and hospital type (university vs community setting) and then analyzed using both univariate (chi 2 , t tests) and multivariate (stepwise logistic regression) techniques. RESULTS: Between 1995 and 2003, 14,517 patients underwent AAA repair (85% for elective and 15% for ruptured AAA). The average age was 71.4 +/- 7.9 years, and 76% were men. For elective cases, open repair was performed in 86% and EVAR in 14%; and for ruptured cases, open repair in 97% and EVAR in 3%. Elective EVAR was associated with lower in-hospital mortality compared with open repair regardless of age. No differences were observed with age after either type of repair for a ruptured aneurysm. Men had a lower in-hospital mortality compared with women for open repair of both elective and ruptured aneurysms. For EVAR, the mortality of an elective repair was lower in men, but there was no difference after a ruptured AAA. In men, the difference in mortality between elective open repair and EVAR was significant; the type of institution did not influence outcome. Patients >80 years of age had a higher mortality after open repair for both elective and ruptured AAA and after EVAR of a ruptured AAA. The average length of stay was 9.9 days for open elective repair, 13.1 days after open repair of a ruptured AAA, and 3.6 days for EVAR. The independent predictors of higher in-hospital mortality were female gender, age >80 years, diagnosis (ruptured vs open), and procedure (open vs EVAR). The year of the procedure and type of hospital (university vs community) were not predictive of outcome. CONCLUSIONS: EVAR has had a significant impact on AAA management in Illinois over a relatively short time period. In this population-based review, EVAR was associated with a significantly decreased in-hospital mortality and length of stay. Octogenarians had higher mortality after both types of repair, with the exception of elective EVAR.     

Endovascular repair of ruptured abdominal aortic aneurysm--a challenge to open repair? Results of a single centre experience in 20 patients.

INTRODUCTION: The mortality from ruptured abdominal aortic aneurysm (AAA) remains in the region of 50% despite advances in critical care. Endovascular repair of AAA has been shown to be associated with reduced physiological stress in the elective setting. It is hypothesised that the reduced physiological stress associated with EVAR may improve the outcome in patients with ruptured AAA. METHODS: A feasibility study of endovascular repair of ruptured AAA was undertaken at the University Hospital, Nottingham, U.K. between 1994 and 2000. Patients admitted with ruptured AAA were assessed by a team familiar with endovascular techniques for elective repair of AAA. After giving informed consent patients underwent spiral computed tomographic angiography (CTA) in the majority of cases. Patients were then transferred to the operating theatre for EVAR. RESULTS: Twenty patients underwent repair of ruptured AAA. Of these 20 patients, seven were referred from another hospital. Eight patients were considered unfit for open repair. The median duration of procedure was 180 min (range 120-480) and median blood loss was 1200 ml (range 750-2000 ml). The overall peri-operative mortality was 45%. A number of intra-operative and peri-operative procedures (both open and endovascular) were required to ensure aneurysm exclusion and to deal with the complications of endovascular surgery. CONCLUSIONS: Ruptured AAA remains a particularly hazardous condition to treat. There are a number of advantages of EVAR in this condition. A number of the problems early in the experience of EVAR have been addressed, but further experience is required to demonstrate its efficacy when compared with open repair.     

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.     

An intention-to-treat by endovascular repair policy may reduce overall mortality in ruptured abdominal aortic aneurysm

OBJECTIVE: The use of endovascular aneurysm repair (EVAR) for ruptured abdominal aortic aneurysm (AAA) has been restricted to a small number of specialized units on a selected group of patients. The aim of this study is to assess if the overall mortality in these patients with ruptured AAA may be reduced in a unit where all patients with ruptured AAA are considered first for EVAR. METHODS: During a 24-month period beginning in July 2002, 51 patients admitted with ruptured AAA were considered for EVAR as the treatment of choice and comprised the study group. EVAR was performed in 17 patients. Open repair was performed in 34 patients: 13 patients had hemodynamic instability and 16 patients had an unsuitable aortic neck anatomy. The study group was compared with a historical control group of 41 patients with ruptured AAA who were treated by open repair from July 2000 to June 2002. RESULTS: Mortality rate was 39% in the study group compared with 59% in the control group (P = .065). The duration of stay in the intensive care unit was significantly lower in the study group than in the control group (P = .01), although the total in-hospital stay was similar (17 days vs 14 days, P = .83). Within the study group, EVAR patients had a mortality rate of 24% compared with 47% in the open group (P = .14). CONCLUSION: Although the number of patients was small, offering EVAR to as many patients as possible with ruptured AAA has resulted in a 20% reduction in mortality, albeit statistically insignificant. However, it is in the unstable patients that EVAR will need to improve survival before it may be hailed to supersede the conventional approach.     

Elevated levels of soluble tumor necrosis factor receptors are associated with increased mortality rates in patients who undergo operation for ruptured abdominal aortic aneurysm

PURPOSE: Elevated levels of soluble tumor necrosis factor receptors (sTNF-Rs) are associated with multiple organ failure and increased mortality rates in critically ill patients. Paradoxically, experimental data suggest exogenous sTNF-Rs may improve outcome in patients who undergo elective abdominal aortic aneurysm (AAA) repair. This study examines, for the first time, changes in sTNF-R levels during repair of ruptured and nonruptured AAA. METHODS: Sixteen patients who underwent surgical procedures for ruptured AAA and 10 patients who underwent surgical procedures for nonruptured AAA were studied. Levels of sTNF-Rs p55 and p75 were measured before the operation and immediately before and 5 minutes, 6 hours, and 24 hours after aortic clamp release. RESULTS: When compared with nonruptured AAA, levels of sTNF-R p55 were significantly higher in ruptured AAA 5 minutes (P <.02) and 24 hours after aortic clamp release (P <.05). Levels of sTNF-R p75 were significantly higher in ruptured AAA before (P <.05), during (P <.001), and after the surgical procedure (P <.01). Six hours after aortic clamp release, sTNF-R p75 levels were significantly higher in nonsurvivors of ruptured AAA when compared with survivors (P <.05) and patients who underwent surgical procedures for nonruptured AAA (P <.01). CONCLUSION: Ruptured AAA repair is associated with increased sTNF-R expression. Furthermore, elevated levels of sTNF-R p75 are associated with increased postoperative mortality rates.     

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.     

Comparison of morphologic features of intact and ruptured aneurysms of infrarenal abdominal aorta

INTRODUCTION: Endovascular aneurysm repair (EVAR) has been suggested as a technique to improve outcome of ruptured abdominal aortic aneurysm (AAA). Whether this technique becomes an established treatment will depend, in part, on the anatomy of ruptured AAA. METHODS: The anatomy of intact and ruptured AAA seen in a university department of vascular surgery over 5 years was reviewed. Aneurysm anatomy was assessed with spiral computed tomographic angiography. Suitability for EVAR was assessed from the dimensions of the proximal neck and common iliac arteries. Neck length less than 15 mm, neck width greater than 30 mm, and common iliac artery diameter greater than 22 mm were declared unsuitable for EVAR. RESULTS: Three hundred sixty-three patients with intact AAA and 46 with ruptured AAA were identified. Larger intact aneurysms were significantly associated with longer renal artery-bifurcation distance and more complex proximal neck architecture. In this sample, patients with ruptured AAA were more likely to have larger aneurysms with shorter and narrower proximal necks. Significantly more intact aneurysms were morphologically suitable for endovascular repair compared with ruptured AAA (78% vs 43%; P <.001). CONCLUSIONS: Ruptured AAA are less likely to be suitable for endovascular repair than are intact AAA, most probably because of larger diameter at presentation. Open repair will likely remain the treatment of choice in most patients with ruptured AAA, because of current morphologic constraints of endovascular repair.     

Variation in death rate after abdominal aortic aneurysmectomy in the United States: impact of hospital volume, gender, and age

OBJECTIVE: To determine whether high-volume hospitals (HVHs) have lower in-hospital death rates after abdominal aortic aneurysm (AAA) repair compared with low-volume hospitals (LVHs). SUMMARY BACKGROUND DATA: Select statewide studies have shown that HVHs have superior outcomes compared with LVHs for AAA repair, but they may not be representative of the true volume-outcome relationship for the entire United States. METHODS: Patients undergoing repair of intact or ruptured AAAs in the Nationwide Inpatient Sample (NIS) for 1996 and 1997 were included (n = 13,887) for study. The NIS represents a 20% stratified random sample representative of all U.S. hospitals. Unadjusted and case mix-adjusted analyses were performed. RESULTS: The overall death rate was 3.8% for intact AAA repair and 47% for ruptured AAA repair. For repair of intact AAAs, HVHs had a lower death rate than LVHs. The death rate after repair of ruptured AAA was also slightly lower at HVHs. In a multivariate analysis adjusting for case mix, having surgery at an LVH was associated with a 56% increased risk of in-hospital death. Other independent risk factors for in-hospital death included female gender, age older than 65 years, aneurysm rupture, urgent or emergent admission, and comorbid disease. CONCLUSIONS: This study from a representative national database documents that HVHs have a significantly lower death rate than LVHs for repair of both intact and ruptured AAA. These data support the regionalization of patients to HVHs for AAA repair.     

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.     

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.     

Epidemiology and Outcome of Aortic Aneurysms in Hong Kong

Abstract The objective of this study was to determine epidemiology and mortality statistics for abdominal aortic aneurysms (AAAs) in Hong Kong. Data from three sources were obtained and analyzed: (1) Hong Kong Hospital Authority discharge statistics for 1999 and 2000; (2) a survey on aortic aneurysms in public hospitals conducted by the Working Group of Vascular Surgery; and (3) the Department of Surgery, University of Hong Kong Medical Center aortic aneurysm database. The disease pattern, distribution, and operative mortality were determined. The annual incidence of AAA in Hong Kong is 13.7 per 100,000 population and 105 per 100,000 for those aged 65 and above. About 10% of the AAAs that presented were ruptured. The mean age of the AAA patients was 74 years, with 84% of them over age 65. The operative repair rate for AAAs was low, being only 8% for intact aneurysms and 54% for ruptured ones. Overall, 45% of all aneurysm repairs were performed for a ruptured AAA. There is diverse practice between major vascular centers and smaller regional hospitals. The territory-wide operative mortality rates for intact and ruptured aneurysms were 10% (range 4–24%) and 70% (range 38––100%), respectively. There was no gender bias in the rupture and operative rates. The overall mortality was 17% for intact AAAs and 78% for ruptured AAAs. The average length of hospital stay was 19 days for elective AAA surgery and 13 days for ruptured AAAs. The number of operations in high-volume centers is increasing with a concomitant decrease in operative mortality. There are no definitive data to indicate that the incidence of AAAs is rising, but a trend toward an increasing number of operations in referral centers is noted. The low repair rates for intact AAAs and the high proportion of repairs for ruptured aneurysms suggest that AAAs are undertreated in Hong Kong.     

Inflammatory aortic aneurysm is associated with increased incidence of autoimmune disease

OBJECTIVE: It has been suggested that certain genetic risk factors indicative of an autoimmune mechanism can be identified in patients with inflammatory aortic aneurysm (IAA). We therefore investigated whether there was a higher incidence of autoimmune diseases in patients with IAA. Further, we explored risk factors, need for in-hospital resources, and early results of treatment, in a case-control study in a university hospital setting.Material and methods From 1983 to 1994, 520 patients were operated because of abdominal aortic aneurysm (AAA). Thirty-one patients had IAA. Control subjects were matched for aneurysm rupture, emergency or elective hospital admission, and date of operation. Two noninflammatory AAA were included for every IAA. RESULTS: Of the 31 patients with IAA, 6 patients (19%) had autoimmune disease, compared with none of the control subjects (P =.0017). Two patients had rheumatoid arthritis, 2 patients had systemic lupus erythematosus, 1 had giant cell arteritis, and 1 patient had an undifferentiated seronegative polyarthritis diagnosed as rheumatoid arthritis. Nineteen patients (61%) with IAA had involvement of the duodenum, and 8 patients (26%) had hydronephrosis with ureteral involvement. Operating time was longer in the IAA group, which also had a higher need for blood transfusion. Hospital stay, intensive care unit stay, and 30-day mortality were similar in the two groups. CONCLUSION: Except for longer operating time and more need for blood transfusions in the IAA group, use of hospital resources was similar after operations to treat IAA or noninflammatory AAA. The study findings indicate an association between IAA and autoimmune disease. This is in accordance with other reports that showed a genetic risk determinant mapped to the human leukocyte antigen (HLA) molecule in these patients. Further research is necessary to explore whether IAA might be a separate entity with a role of antigen binding in the origin of the disease.     

Four-year follow up of patients with untreated abdominal aortic aneurysms

BACKGROUND: The data in the literature are still controversial describing the outcome of patients not treated for a large abdominal aortic aneurysm (AAA) especially with significant comorbidities. We followed up patients trying to establish their long-term outcome. METHOD: Since 1998, we have prospectively followed all patients referred to our department with AAA. A retrospective analysis was carried out selecting all patients who had an AAA larger than 5 cm, and who declined or were declined for operative repair between February 1998 and November 2001. RESULTS: One hundred and eleven patients were included in the present study. There were 78 men and 33 women. The mean age was 80 years. At the end of the study, 65 patients (59%) were deceased. Ruptured aneurysm occurred in 27 patients (median time to rupture = 14 months) with one patient surviving an emergency repair. Thirty-nine patients died from unrelated illnesses. In the 5-5.9 cm AAA group (n = 58), out of 31 deceased patients, five (16%) have died of ruptured AAA. In the 6 cm and larger AAA group (n = 53), out of 34 deceased patients, 21 (62%) have died of ruptured AAA. There was no significant difference in survival between patients with AAA below and above 6 cm in diameter (P = 0.15). CONCLUSION: In the presence of significant comorbidities, most patients with AAA less than 6 cm died from unrelated illnesses. In the larger AAA group, the likelihood of death from AAA rupture or unrelated illnesses is almost equal.     

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.