Clinical ResearchOpen Repair for Ruptured Abdominal Aortic Aneurysm: Is It Possible to Predict Survival?
Introduction
Despite the increase in numbers of elective abdominal aortic aneurysm (AAA) repair, the number of patients with ruptured AAA (RAAA) has not been significantly reduced.1, 2, 3 Whereas the surgical mortality rate for elective repair of AAA has steadily improved by about 5%, the mortality rates after repair of RAAA have not significantly changed in the literature in the last three decades, still ranging 30-50% in the most recent reports.4, 5, 6, 7, 8, 9
Many different factors have been advocated to be predictive of death, including age, comorbidity, medical condition, preoperative shock or hypotension, increased creatinine level, low hemoglobin/hematocrit level, and technical and postoperative complications; but none of these was really able to predict correctly the outcome of these patients.5, 8, 10, 11, 12 Scoring systems have been developed to identify those patients who are at high risk of postoperative mortality or morbidity; however, most of them are complex and not usable in the emergent setting. The Glasgow Aneurysm Score (GAS) has been proved to be a simple and effective method to identify preoperatively patients at high risk for emergent AAA repair.13, 14 The Acute Physiology Chronic Health Evaluation II (APACHE-II) model is the only available model specifically developed for predicting outcome in the postoperative period for patients managed in the intensive unit care (IUC).15, 16 The aim of this retrospective study was to determine significant variables that could be used to predict survival in patients who underwent emergent repair for RAAA and to evaluate the accuracy of GAS and APACHE-II as models of prediction of in-hospital mortality.
Section snippets
Patients And Methods
Data of all patients admitted to the Department of Vascular and Endovascular Surgery of the University of Padua for RAAA between January 1998 and July 2006 were retrospectively collected in a database and thereafter analyzed.
RAAA was defined as a defect in the aneurysmal wall that had allowed extravasation of a quantity of blood. Patients with ruptured thoracoabdominal aneurysm, isolated iliac artery aneurysm, or pseudoaneurysm and symptomatic patients who had surgery without retroperitoneal
Results
From January 1998 to July 2006, 1,141 patients underwent AAA repair at the Department of Vascular Surgery of Padua University. There were 1,008 elective procedures, and 251 (24.9%) of these were endovascular treatment; 169 (16.7%) patients underwent emergency operations for symptomatic AAA, 127 of whom had evidence of rupture. Of these, 11 patients (8.6%) were considered unfit for surgery due to prohibitive comorbidity; six were men and five were women, of median age 87 (range 80-95) years.
Discussion
The mortality rate of ruptured aneurysms remains remarkably high. With the exception of a few series,17, 18 this is from 30% to more than 70% in most reports.19 If patients who died at home or during transport to a hospital are included, the mortality rate approaches 90%.20, 21 This excessively high operative mortality rate could be explained because patient selection is usually impossible and the majority already suffer the consequences of hypovolemic shock at admission. A report by Johansen
Conclusion
Despite the large number of recent reports that have studied this subject, controversy remains; and in accordance with some authors, we conclude that there are no preoperative characteristics or scoring system that allow us to withhold emergency surgical repair for RAAA. The ideal treatment of RAAA remains its prevention and, when not possible, to identify the patients in whom preoperative conditions and other preoperative clinical factors make conventional repair inopportune.
The role of
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2012, European Journal of Vascular and Endovascular SurgeryCitation Excerpt :They have to make a choice whether to urgently operate a patient, who may not be optimised for major surgery, or to postpone surgery until regular preoperative work-up is completed. Historically, urgent S-AAA repair has had a worse perioperative outcome than elective E-AAA repair.13,22–27 Postponing surgery, however, includes a risk of interval rupture, which is associated with an even higher mortality rate.5,6
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