Abstract P4-15-02: Clinical, biochemical, and genomic predictors of trastuzumab-related cardiotoxicity: Results of CATS

Background: Adjuvant therapy for HER2-positive breast cancer (HBC) often comprises anthracyclines (A) followed by trastuzumab (T). Trastuzumab-related cardiotoxicity (TRC) is T’s primary toxicity, and led 15% of patients in NSABP-B31 to stop T early. Earlier detection of TRC might enable timely therapeutic intervention, lowering the number of patients ceasing T prematurely. Small, retrospective, unvalidated studies have proposed various markers as predictors for TRC. The Cardiotoxicity of Adjuvant Trastuzumab Study (CATS) aims to assess a panel of clinical, biochemical, and genomic/immunologic markers as predictors for TRC.

Methods: HBC patients with a left ventricular ejection fraction (LVEF) ≥ 50% scheduled to receive adjuvant A followed by 12 months’ T were eligible. Serum N-terminal pro-B type natriuretic peptide (NT pro-BNP) and troponin I were measured centrally at baseline (T1), at completion of A (T2), and after 3 and 6 months of T. LVEF was measured at T1, T2, and then 3-monthly until completion of T. Germline SNPs in ERBB2 (V655I), FCGR2A (H131R), and FCGR3A (V158F) were assessed. TRC was defined as: cardiac death, NYHA class 3/4 heart failure, grade 3/4 arrhythmia/ischemia, drop in LVEF >15% from baseline, or drop in LVEF of >10% to <55%. 1 patient with LVEF <50% at T2 was excluded. Uni- and multivariate logistic regression were used to determine features associated with TRC. Serum markers were added to the model using forward selection.

Results: 17 centers enrolled 222 patients (217 evaluable). Patient characteristics are shown.

Baseline characteristicsAge [median (range), yrs]52 (28-77)Baseline LVEF [median (range)]64% (50-82%)Left-sided tumors [n(%)]105 (48%)History of hypertension [n(%)]48 (22%)Doxorubicin [n(%), median total dose]80 (37%), 242mg/m2Epirubicin [n(%), median total dose]137 (63%), 300mg/m2Concurrent taxane with T [n(%)]217 (100%)

TRC occurred in 33 patients (15.2%). In multivariate models, lower baseline LVEF (OR 3.23 for a 5% lower LVEF, [95% CI 1.96-5.33], p<0.0001) and greater absolute decline in LVEF from T1 to T2 (OR 3.25 for each 5% drop in LVEF, [95%CI 1.83-5.79], p<0.0001] were each independent predictors of TRC. NT pro-BNP increased from T1 to T2 (median Δ=1.31pmol/L, p<0.0001) and then fell to baseline levels. Troponin I increased from T1 to T2 in 64.5% of patients (p<0.0001) and remained above baseline 6 months post-A (p<0.0001). NT pro-BNP and troponin I at T1 were not predictive for TRC. There were trends for the absolute increase in NT-pro BNP and troponin I from T1 (pre-A) to T2 (post-A) to be associated with risk of TRC (p=0.08 and 0.09) in univariate analyses. Germline SNPs were not predictive of TRC.

Conclusion: This is the largest prospective study analyzing predictors for TRC, and the first studying immune-related SNPs in this context. Consistent with the literature, lower LVEF at baseline increases risk of TRC. Previously unreported, the absolute decrease in LVEF after A is also predictive for TRC. The persistent elevation of troponin I 6 months after completing A demonstrates chronic cardiac stress during therapy. Ongoing modeling analyses (to be presented at the meeting) will determine whether longitudinal changes in serum biomarkers can predict subsequent development of TRC.

Citation Format: Shom Goel, Hao Guo, William Barry, Bronwyn Murray, Jodi Lynch, Patricia Bastick, Lorraine Chantrill, Belinda Kiely, Richard Bell, Ehtesham Abdi, Josie Rutovitz, Ray Asghari, Anne Sullivan, Michelle Harrison, Maija Kohonen-Corish, Jane Beith. Clinical, biochemical, and genomic predictors of trastuzumab-related cardiotoxicity: Results of CATS [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P4-15-02.

A cost effective analysis of a laparoscopic versus an open left lateral sectionectomy in a liver transplant unit

INTRODUCTION

This study aimed to assess the cost effectiveness of a laparoscopic left lateral sectionectomy (LLLS) compared with an open (OLLS) procedure and its role as a training operation as well as the learning curve associated with a laparoscopic approach.

METHOD

Between 2004 and 2013, a prospectively maintained database was reviewed. LLLS were compared with age- and sex-matched OLLS. In addition, the outcomes of LLLS with a consultant as the primary surgeon were compared with those performed by trainees.

RESULTS

Forty-three LLLS were performed during the study period. LLLS was a significantly cheaper operation compared with OLLS (P = 0.001, £3594.14 versus £5593.41). The median hospital stay was shorter in the laparoscopic group (P = 0.002, 3 versus 7 days). No difference was found in outcomes between a LLLS performed by a trainee or consultant (operating time, morbidity or R1 resection rate). The procedure length was significantly shorter during the later half of the study period [120 versus 129 min (P = 0.045)].

CONCLUSION

LLLS is a significantly cost effective operation compared with an open approach with a reduction in hospital stay. In addition, it is suitable to use as a training operation.

Remote sensing for assessing the zone of benefit where deep drains improve productivity of land affected by shallow saline groundwater

The installation of deep drains is an engineering approach to remediate land salinised by the influence of shallow groundwater. It is a costly treatment and its economic viability is, in part, dependent on the lateral extent to which the drain increases biological productivity by lowering water tables and soil salinity (referred to as the drains' zone of benefit). Such zones may be determined by assessing the biological productivity response of adjacent vegetation over time. We tested a multi-temporal satellite remote sensing method to analyse temporal and spatial changes in vegetation condition surrounding deep drainage sites at five locations in the Western Australian wheatbelt affected by dryland salinity-Morawa, Pithara, Beacon, Narembeen and Dumbleyung. Vegetation condition as a surrogate for biological productivity was assessed by Normalised Difference Vegetation Index (NDVI) during the peak growing season. Analysis was at the site scale within a 1000 m buffer zone from the drains. There was clear evidence of NDVI increasing with elevation, slope and distance from the drain. After accounting for elevation, slope and distance from the drain, there was a significant increase in NDVI across the five locations after installation of deep drains. Changes in NDVI after drainage were broadly consistent with measured changes at each site in groundwater levels after installation of the deep drains. However, this study assessed the lateral extent of benefit for biological productivity and gave a measure of the area of benefit along the entire length of the drain. The method demonstrated the utility of spring NDVI images for rapid and relatively simple assessment of the change in site condition after implementation of drainage, but approaches for further improvement of the procedure were identified.

Meta-analysis of antecolic versus retrocolic gastric reconstruction after a pylorus-preserving pancreatoduodenectomy

INTRODUCTION

Delayed gastric emptying (DGE) is a common complication after a pylorus-preserving pancreatoduodenectomy (PPPD) and is associated with significant morbidity. This study determines whether DGE is affected by antecolic (AC) or retrocolic (RC) reconstruction after a PPPD.

METHOD

An electronic search was performed of the MEDLINE, EMBASE and PubMed databases to identify all articles related to this topic. Pooled risk ratios (RR) were calculated for categorical outcomes, and mean differences (MD) for secondary continuous outcomes using the fixed-effects and random-effects models for meta-analysis.

RESULTS

Nine studies including 878 patients met the inclusion criteria. DGE was lower with an AC reconstruction RR 0.31 [0.12, 0.78] Z = 2.47 (P = 0.010). Length of stay (LOS) MD -4 days [-7.63, -1.14] Z = 2.65 (P = 0.008) and days to commence a solid diet MD -5 days [-6.63, -3.15] Z = 5.50 (P ≤ 0.000) were also significantly in favour of the AC group. There was no difference in the incidence of pancreatic fistula, intra-abdominal collection/bile leak or mortality between the two groups.

CONCLUSION

AC reconstruction after PPPD is associated with a lower incidence of DGE. Time to oral intake was significantly shorter with AC reconstruction, with a reduced hospital stay.

Meta-analysis of Duct-to-duct versus Roux-en-Y biliary reconstruction following liver transplantation for primary sclerosing cholangitis

This meta-analysis aimed to compare outcomes following bile duct reconstruction in patients with primary sclerosing cholangitis (PSC) undergoing liver transplantation depending on whether duct-to-duct or Roux-en-Y anastomosis was utilized. An electronic search was performed of the MEDLINE, EMBASE, PubMed databases using both subject headings (MeSH) and truncated word searches. Pooled risk ratios and mean difference were calculated using the fixed-effects and random-effects models for meta-analysis. Ten studies including 910 patients met the inclusion criteria. There was no difference in the overall incidence of biliary strictures between the two groups [odds ratio (OR) 1.06 (0.68, 1.66); (P = 0.80)]. The anastomotic stricture rate was similar, [OR 1.18 (0.56, 2.50); (P = 0.67)]. Ascending cholangitis was higher in the Roux-en-Y group [OR 2.91 (1.17, 7.23); (P = 0.02)]. Anastomotic bile leak rates, graft survival, PSC recurrence and number of patients diagnosed with cholangiocarcinoma following transplantation were comparable between both groups. Duct-to-duct and Roux-en-Y reconstruction had comparable outcomes. Both techniques are associated with similar incidence of biliary stricture. The bilioenteric reconstruction was associated with a higher risk of cholangitis. The incidence of de novo cholangiocarcinoma was similar in both groups. Duct-to-duct reconstruction should be considered when feasible in patients with PSC.

Systemic treatment of HER2+ metastatic breast cancer: clinical conundrums and future perspectives

Improvements in the treatment of metastatic HER2-positive breast cancer constitute one of the great advances in breast cancer medicine of the last generation. From being a highly aggressive fatal condition, the use of anti-HER2-targeted therapies, in particular trastuzumab, has led to significant improvements in disease outcomes. There are reports of increasing numbers of patients alive and well more than 5 years from diagnosis of metastatic disease. Nevertheless, there remain many complex and clinically difficult scenarios where there is little in the way of randomized evidence or published guidelines to guide decision making. As a companion piece to our review of HER2-targeted therapies in the metastatic setting, we decided to focus on a series of clinical scenarios that fell outside of the standard trial-based settings and where opinions and guidance from experienced clinicians and experts in the field would be considered useful to help develop safe and effective treatment strategies. The following eight cases were put forward by our panel of experts, voted on by their peers to select the most relevant and interesting cases, and the discussions worked on by teams of two followed by review and commentary by another team of two.

A multi-agency evaluation of the Leeds Dual Diagnosis care co-ordination protocol

Purpose

– The purpose of this paper is to demonstrate the learning from the multi-agency evaluation of the Leeds Dual Diagnosis Care co-ordination protocol undertaken by the Leeds Dual Diagnosis (DD) Project in 2013. The evaluation aimed to identify the prevalence of people with DD accessing network member services, and to identify the standard of care network members provided for people with DD in relation to the Leeds Care Co-ordination Protocol.

Design/methodology/approach

– The evaluation adopted a service evaluation methodology and included features of real world research. Two standardised self-completion questionnaires were administered using Survey Monkey™ software.

Findings

– The majority of service could provide prevalence data however the quality of data provided was significantly impacted by the limitations of client management systems. Completion of specific DD training beyond basic awareness was generally low and many participants were confused about the different levels of training available. Standards of care varied, a substantial amount of joint working was taking place via informal pathways which relied on established relationships and trust between practitioners and services. Jointing working was often informal when people were not under the Care Programme Approach.

Research limitations/implications

– Due of the methodological choices the evaluation cannot be considered impartial. The prevalence data gathered lacks robustness and does not reflect the number of people who meet clinical threshold for DD as valid screening tools were not used by all services. The standards of care identified only reflect practitioner's personal views and do not provide a definitive answer to the standard of care being delivered. The response rate in relation to standards of care was low with large amounts of missing data negatively impacting the external validity of data gathered.

Practical implications

– The completion of this evaluation demonstrates that it is extremely challenging to undertake a multi-agency evaluation with limited resources. It has highlighted key challenges and areas for future development locally in relation to DD. The themes explored are likely to be of interest to commissioners, service managers, DD consultant nurses and anyone involved in the strategic development of DD.

Originality/value

– The evaluation has generated information which is of practical significance to local commissioners and Leeds DD Network Members. The knowledge and learning from this evaluation has subsequently been used by the Leeds DD Strategy Group to inform the new action plan for the DD Project, the re-commissioning of substance misuse services and the new mental health framework being developed for Leeds.

Wheat responses to sodium vary with potassium use efficiency of cultivars

The role of varied sodium (Na) supply in K nutrition of wheat (Triticum aestivum L.) is not well understood especially among cultivars differing in K efficiency. We examined the response of K-efficient and K-inefficient Australian wheat cultivars to Na supply (low to high Na) under K-deficient and K-adequate conditions. In a pot experiment, wheat cvv Wyalkatchem, Cranbrook (K-efficient), and cvv Gutha, Gamenya (K-inefficient) were grown for 8 weeks in a sandy soil containing 40 or 100 mg K/kg in combination with nil, 25, 50, 100, or 200 mg Na/kg. High soil Na levels (100, 200 mg Na/kg) greatly reduced plant growth in all four cultivars especially at low soil K (40 mg K/kg). By contrast, low to moderate soil Na levels (25, 50 mg Na/kg) stimulated root dry weight at low K supply, particularly in K-efficient cultivars compared with K-inefficient cultivars. At low K supply, low to moderate Na failed to increase shoot Na to a concentration where substitution of K would be feasible. However, low to moderate Na supply increased shoot K concentration and content in all four wheat cultivars, and it increased leaf photosynthesis and stomatal conductance to measured values similar to those under adequate K and nil Na conditions. The results showed that low to moderate Na stimulated K uptake by wheat particularly in K-efficient cultivars and through increased shoot K enhanced the photosynthesis. We conclude that increased photosynthesis supplied more assimilates that led to increased root growth and that greater root growth response of K-efficient cultivars is related to their greater K-utilization efficiency. However, the process by which low to moderate Na increased shoot K content warrants further investigation.

Women with pre-gestational diabetes have a higher risk of stillbirth at all gestations after 32 weeks

AIM

To explore the additional risk of stillbirths and to quantify that risk according to gestational age among women with diabetes.

METHODS

Data on pregnancies ending in 2007 and 2008 in women with pre-gestational diabetes in three English regional audits were identified. A prospective audit collected data on all pregnancies delivering between June 2010 and May 2011 in one region and in 13 other units across England. The data on all singleton pregnancies from these two cohorts were combined. Comparisons were made to all births in England and Wales for the same time period using data from the Office for National Statistics.

RESULTS

In the cohort of women with pre-gestational diabetes there were a total of 2085 singleton pregnancies, of which 29 resulted in a stillbirth (overall stillbirth rate 13.9 per 1000, 95% CI 9.7-19.9, relative risk compared with all pregnancies in England and Wales 2.73, 95% CI 2.61-2.84). The relative risk of stillbirth between 32 and 34 weeks' gestation was 4.95 (95% CI 4.24-5.78), 3.77 (95% CI 3.42-4.16) at 35 to 36 weeks, 5.75 (95% CI 5.43-6.09) for deliveries at 37 or 38 weeks and 7.34 (95% CI 6.52-8.25) for those born at 39 weeks or more.

CONCLUSION

Women with diabetes have a significantly higher risk of stillbirth at all gestations after 32 weeks and this additional risk is not just confined to pregnancies at 37 weeks or more.

Fifteen-year trends and predictors of preparation for pregnancy in women with pre-conception Type 1 and Type 2 diabetes: a population-based cohort study

AIMS

To investigate trends in indicators of preparation for pregnancy in women with Type 1 and Type 2 diabetes and explore their predictors.

METHODS

Data on 2293 pregnancies delivered during 1996-2010 by women with Type 1 (n = 1753) and Type 2 (n = 540) diabetes were obtained from the Northern Diabetes in Pregnancy Survey. Multiple logistic regression was used to analyse the relationship between potential predictors and three indicators of inadequate pregnancy preparation: non-attendance for pre-conception care; no pre-conception folate consumption; and peri-conception HbA(1c) ≥ 53 mmol/mol (≥ 7%).

RESULTS

Overall, 40.3% of women with diabetes attended pre-conception care, 37.4% reported pre-conception folate consumption, and 28.2% had adequate peri-conception HbA1c . For all patients, pre-conception folate consumption improved over time, while peri-conception glucose control did not. Attendance for pre-conception care for women with Type 1 diabetes significantly declined. Residence in deprived areas, smoking and younger maternal age (for women aged < 35 years) were independently associated with all three indicators of inadequate preparation for pregnancy. Additional predictors of inadequate peri-conception HbA(1c) were: Type 1 diabetes (adjusted odds ratio 5.51, 95% CI 2.71-11.22), longer diabetes history (adjusted odds ratio 1.16, 95% CI 1.09-1.23 per year increase for those with < 15 years' diabetes duration), non-white ethnicity (adjusted odds ratio 3.13, 95% CI 1.23-7.97) and higher BMI (adjusted odds ratio 1.05, 95% CI 1.01-1.09 per 1-kg/m(2) increase). Non-attendance for pre-conception care was additionally associated with Type 2 diabetes (P = 0.003) and multiparity (P < 0.0001).

CONCLUSIONS

There are socio-demographic inequalities in preparation for pregnancy among women with diabetes. Women with Type 2 diabetes were less likely to attend pre-conception care. Pre-conception services need to be designed to maximize uptake in all groups.

Adjuvant zoledronic acid in patients with early breast cancer: final efficacy analysis of the AZURE (BIG 01/04) randomised open-label phase 3 trial

BACKGROUND

The role of adjuvant bisphosphonates in early breast cancer is uncertain. We therefore did a large randomised trial to investigate the effect of the adjuvant use of zoledronic acid on disease-free survival (DFS) in high-risk patients with early breast cancer.

METHODS

In the AZURE trial, an open-label, international, multicentre, randomised, controlled, parallel-group phase 3 trial, women (age ≥18 years) with stage II or III breast cancer were randomly assigned (1:1) by a central automated 24-h computer-generated telephone minimisation system (balanced for number of involved axillary lymph nodes, tumour stage, oestrogen receptor status, type and timing of systemic therapy, menopausal status, statin use, and treatment centre) to receive standard adjuvant systemic treatment alone (control group) or with 4 mg intravenous zoledronic acid every 3-4 weeks for six doses, then every 3 months for eight doses, followed by every 6 months for five doses, for a total of 5 years of treatment. The primary endpoint was disease-free survival (DFS). Secondary endpoints were invasive DFS (IDFS), overall survival, time to bone metastases, time to distant recurrence, and subgroup analyses of variables included in the randomisation. All patients have completed study treatment. Results from the intention-to-treat final analysis of this fully recruited study are presented after a median follow-up of 84 months (IQR 66-93). This final efficacy analysis was planned to take place after 940 DFS events. This trial is registered with ClinicalTrials.gov, NCT00072020.

FINDINGS

3360 women were recruited from 174 centres in seven countries between Sept 4, 2003, and Feb 16, 2006. The number of DFS events did not differ between groups: 493 in the control group and 473 in the zoledronic acid group (adjusted hazard ratio [HR] 0·94, 95% CI 0·82-1·06; p=0·30). IDFS (HR 0·93, 95% CI 0·82-1·05; p=0·22), overall survival (0·93, 0·81-1·08; p=0·37), and distant recurrences (0·93, 0·81-1·07; p=0·29) were much the same in both groups. Zoledronic acid reduced the development of bone metastases, both as a first event (HR 0·78, 95% CI 0·63-0·96; p=0·020) and at any time during follow-up (0·81, 0·68-0·97; p=0·022). The effects of zoledronic acid on DFS were not affected by oestrogen-receptor status. However, zoledronic acid improved IDFS in those who were over 5 years since menopause at trial entry (n=1041; HR 0·77, 95% CI 0·63-0·96) but not in all other (premenopause, perimenopause, and unknown status) menopausal groups (n=2318; HR 1·03, 95% CI 0·89-1·20). 33 cases of suspected osteonecrosis of the jaw have been reported, with 26 confirmed on central review, all in the zoledronic acid group (1·7%, 95% CI 1·0-2·4).

INTERPRETATION

These results suggest no overall benefit from the addition of zoledronic acid to standard adjuvant treatments for early breast cancer. However, zoledronic acid does reduce the development of bone metastases and, for women with established menopause, improved disease outcomes.

FUNDING

Novartis Global and NIHR Cancer Research Network.

Trastuzumab-Associated Cardiac Events at 8 Years of Median Follow-Up in the Herceptin Adjuvant Trial (BIG 1-01)

Purpose

To document the rate and outcome of trastuzumab-associated cardiac dysfunction in patients following 1 or 2 years of adjuvant therapy.

Patients and Methods

The Herceptin Adjuvant (HERA) trial is a three-arm, randomized trial comparing 2 years or 1 year of trastuzumab with observation in 5,102 patients with human epidermal growth factor receptor 2 (HER2) –positive early-stage breast cancer. Cardiac function was closely monitored. Eligible patients had left ventricular ejection fraction (LVEF) ≥ 55% at study entry following neoadjuvant chemotherapy with or without radiotherapy. This 8-year median follow-up analysis considered patients randomly assigned to 2 years or 1 year of trastuzumab or observation.

Results

The as-treated safety population for 2 years of trastuzumab (n = 1,673), 1 year of trastuzumab (n = 1,682), and observation (n = 1,744) is reported. Cardiac adverse events leading to discontinuation of trastuzumab occurred in 9.4% of patients in the 2-year arm and 5.2% of patients in the 1-year arm. Cardiac death, severe congestive heart failure (CHF), and confirmed significant LVEF decrease remained low in all three arms. The incidence of severe CHF (0.8%, 0.8%, and 0.0%, respectively) and confirmed significant LVEF decrease (7.2%, 4.1%, and 0.9%, respectively) was significantly higher in the 2-year and 1-year trastuzumab arms compared with the observation arm. Severe CHF was the same for 2-year and 1-year trastuzumab. Of patients with confirmed LVEF decrease receiving 2-year trastuzumab, 87.5% reached acute recovery. Of patients with confirmed LVEF decrease receiving 1-year trastuzumab, 81.2% reached acute recovery.

Conclusion

Long-term assessment at 8-year median follow-up confirms the low incidence of cardiac events for trastuzumab given sequentially after chemotherapy and radiotherapy, and cardiac events were reversible in the vast majority of patients.

Epidural versus local anaesthetic infiltration via wound catheters in open liver resection: a meta-analysis

BACKGROUND

This meta-analysis was designed to systematically analyse all published studies comparing local anaesthetic infiltration with wound catheters and epidural catheters in open liver resection.

METHODS

A literature search was performed using the Cochrane Colorectal Cancer Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials in the Cochrane Library, MEDLINE, Embase and Science Citation Index Expanded. Randomized trials, and prospective and retrospective studies comparing wound catheters with epidural catheters were included. Statistical analysis was performed using Review Manager Version 5.2 software. The primary outcome measures were pain scores in the post-operative period operation. Secondary outcome measures were hospital stay, time to opening bowels, overall complications and analgesia-specific complications.

RESULTS

Four studies including 705 patients were included in the analysis. The pain scores were significantly lower in those patients with epidural on the first post-operative day (POD) (mean difference of -0.90 [-1.29, -0.52], Z = 4.61) (P < 0.00001) with comparable pain scores on PODs 2 and 3. There was no significant difference in the time to opening bowels, opioid use and hospital stay between the techniques. The post-operative complication rate was higher in the epidural group (risk ratio 1.40 [1.07, 1.83]; χ(2) = 0.60, df = 1) (P = 0.44); I(2) = 0%; Z = 2.42 (P = 0.02).

CONCLUSION

Local anaesthetic infiltration via wound catheters combined with patient-controlled opiate analgesia provides comparable pain relief to epidural catheters except for the first POD. Both techniques are associated with similar hospital stay and opioid use with wound catheters associated with lower complication rate.

Observations from the IMPROVE trial concerning the clinical care of patients with ruptured abdominal aortic aneurysm

BACKGROUND

Single-centre series of the management of patients with ruptured abdominal aortic aneurysm (AAA) are usually too small to identify clinical factors that could improve patient outcomes.

METHODS

IMPROVE is a pragmatic, multicentre randomized clinical trial in which eligible patients with a clinical diagnosis of ruptured aneurysm were allocated to a strategy of endovascular aneurysm repair (EVAR) or to open repair. The influences of time and manner of hospital presentation, fluid volume status, type of anaesthesia, type of endovascular repair and time to aneurysm repair on 30-day mortality were investigated according to a prespecified plan, for the subgroup of patients with a proven diagnosis of ruptured or symptomatic AAA. Adjustment was made for potential confounding factors.

RESULTS

Some 558 of 613 randomized patients had a symptomatic or ruptured aneurysm: diagnostic accuracy was 91·0 per cent. Patients randomized outside routine working hours had higher operative mortality (adjusted odds ratio (OR) 1·47, 95 per cent confidence interval 1·00 to 2·17). Mortality rates after primary and secondary presentation were similar. Lowest systolic blood pressure was strongly and independently associated with 30-day mortality (51 per cent among those with pressure below 70 mmHg). Patients who received EVAR under local anaesthesia alone had greatly reduced 30-day mortality compared with those who had general anaesthesia (adjusted OR 0·27, 0·10 to 0·70).

CONCLUSION

These findings suggest that the outcome of ruptured AAA might be improved by wider use of local anaesthesia for EVAR and that a minimum blood pressure of 70 mmHg is too low a threshold for permissive hypotension.