Ruptured aneurysm of the infrarenal abdominal aorta: impact of age and postoperative complications on mortality

The beneficial place for the treatment of ruptured abdominal aortic aneurysms

OBJECTIVE

To study the beneficial place for the treatment of ruptured abdominal aortic aneurysms (RAAAs).

METHOD

A retrospective chart review of consecutive RAAA patients was performed. Patients were divided into two groups: direct group and transfer group. We retrospectively reviewed patients' hospital charts and recorded various clinical factors apparent on presentation. The primary consequence was mortality during hospitalization, and some other parameters such as duration of intensive care unit (ICU). All patients were followed up at 1 month, 3 months, 6 months and one year after discharge.

RESULTS

During 4-year period, 56 RAAA patients were treated (24 in direct group, and 32 in transfer group). Significant differences were shown for systolic blood pressure, pulse oxygen saturation, hemoglobin, the time interval from diagnosis to operation et al. There was no difference concerning age and comorbidity among two groups. All the patients were treated by open surgical aneurysm repair. The mortality rate was 68.8% ((6 + 16)/32) in transfer group and 33.3% (8/24) in direct group (P = 0.00067). Both the duration of ICU stay and entire hospitalization were a bit longer in the transfer group, but there was no significant difference. The mean follow-up time was 25.2 ± 12.9 months. The cumulative survival difference was significant (P = 0.042) between the two groups.

CONCLUSION

It is beneficial that we treat RAAAs in the diagnosed hospital. The reasons are: 1) to avoid the development of unstable state of aneurysm after rupturing of stable state; 2) the time interval from initial symptoms to operation will be shortened.

Predictors of postoperative mortality of ruptured abdominal aortic aneurysm: a retrospective clinical study

PURPOSE

Despite significant improvements in surgery, anesthesia, and postoperative critical care, the postoperative mortality rate of ruptured abdominal aortic aneurysm (RAAA) has remained at 40% to 50% for several decades. Therefore, we evaluated factors associated with the postoperative mortality of RAAA.

MATERIALS AND METHODS

From January 1999 to December 2008, a retrospective study was performed with 34 patients who underwent open repair of RAAA. The preoperative factors included age, sex, smoking, comorbidities, serum creatinine, hemoglobin, shock, pulse rate, and time from emergency room to operation room. The intraoperative factors included blood loss, transfusion, aortic clamping site and time, aneurysmal characteristics, rupture type, graft type, hourly urine output (HUO), and operative time. The postoperative factors included inotropic support, renal replacement therapy (RRT), reoperation, bowel ischemia, multiple organ failure (MOF), and intensive care unit stay. The 2-day and the 30-day mortality rates were analyzed separately.

RESULTS

The 2-day and the 30-day mortality rates were 14.7% and 41.2%, respectively. On univariate analysis, shock, transfusion, HUO, inotropic support and MOF for the 2-day mortality and serum creatinine, transfusion, aortic clamping site, HUO, inotropic support, RRT and MOF for the 30-day mortality were statistically significant. On multivariate analysis, shock, inotropic support and MOF for the 2-day mortality and aortic clamping site, RRT and MOF for the 30-day mortality were statistically significant.

CONCLUSION

To decrease the postoperative mortality rate of RAAA, prevention of massive hemorrhage and acute renal failure with infrarenal aortic clamping, as well as prompt operative control of bleeding and maintenance of systemic perfusion are important.

Open surgery in endovascular aneurysm repair era: simplified classification in two risk groups owing to factors affecting mortality in 137 ruptured abdominal aortic aneurysms (RAAAs)

Our objective is to identify in 137 true RAAAs operated consecutively in open surgery: (1) diagnostic therapeutic aspects capable of influencing results, (2) risk classes with different prognosis, (3) any situations where the prognosis is so negative that surgery is not recommended. The relationship of 16 anamnestic, clinical and technical parameters prospectively collected with 30-day mortality was retrospectively evaluated by uni- and multivariate analyses. Thirty-day mortality was 37%. The univariate analysis identified as mortality predictors Hb ≤ 8 g/dl and circulatory shock at hospitalisation, but following the multivariate analysis only circulatory shock was a certainly significant risk-factor. The cumulative effect on mortality of the two parameters identified at univariate analysis translates into a statistically significant difference in mortality between two groups of patients: A (no or just one risk-factor) and B (two risk-factors). To reinstate euvolemia, rather than adequate haemoglobin values, improves the chances of success. A simple prognostic index into two risk classes is feasible, but abstention from surgery is not justified in any type of patient.

Do scoring systems help in predicting survival following ruptured abdominal aortic aneurysm surgery?

INTRODUCTION

The aim of this study was to assess the value of the Hardman Index and the Glasgow Aneurysm Score in predicting postoperative mortality in patients with ruptured abdominal aortic aneurysm (rAAA), and to assess the correlation between the two.

PATIENTS AND METHODS

Patients admitted with rAAA were identified from a hospital database. Hospital records were reviewed and a retrospective Hardman Index and Glasgow Aneurysm Score was calculated. Poor postoperative prognosis was considered at a Glasgow Aneurysm Score > 95 or a Hardman Index >or= 3.

RESULTS

A total of 96 patients with a median age of 77.5 years (interquartile range, 71-83 years) and a male:female ratio of 2:1 were identified. Of these, 37 patients were not offered surgery and this was associated with 100% mortality. Of the 59 operated patients, 36 (61%) patients died postoperatively. Operated patients had a median Glasgow Aneurysm Score of 91 (interquartile range, 77-101) and a Hardman Index of 2 (interquartile range, 1-2). In this group, a Glasgow Aneurysm Score > 95 or a Hardman Index >or= 3 was not associated with mortality (P = 0.10 and P = 0.79, respectively). Correlation between the scoring systems was poor (+0.42 tau(b)).

CONCLUSIONS

The scoring systems assessed did not help predict the outcome of rAAA surgery, and correlated poorly with each other. They do not aid clinical judgement.

Successful repair of a giant abdominal aortoiliac aneurysm in a Jehovah's Witness

We report the case of a 76-year-old man of the Jehovah's Witness faith who had a giant abdominal aortoiliac aneurysm that was successfully operated on using an aortoiliac Y-graft bypass technique, without the use of stored allogenic blood. Cell saver technique and recombinant human erythropoietin (epoetin beta) were used during the perioperative period. The patient had good postoperative care with a multidisciplinary approach.

Complications of major aortic and lower extremity vascular surgery

Atheromatous disease and invasive intervention of the aortoiliac and distal arteries are common. Morbidity and mortality have been reduced through understanding and management of patient risk factors. Complications of this form of treatment affect all organ systems; mortality is most frequently caused by a cardiovascular complication (eg, myocardial infarction). Infection, leading to aortoenteric fistula is a dreaded complication, and paraplegia, though rare, is a devastating outcome. Multiorgan failure and death may result from a systemic inflammatory response syndrome. Vascular surgery for infrainguinal disease also has a significant cardiovascular complication rate. Resulting complications may affect all organs; loss of an extremity may occur. The first part of this article reviews perioperative and postoperative complications of open aortic repair and lower-extremity revascularization and addresses the issue of regional anesthesia for major vascular surgery. The second part reviews endovascular aortic repair (EVAR). EVAR is a new intervention that combines surgery and radiology. Complications of EVAR are similar to open repair, but early results suggest they may be less frequent. New technology leads to new complications; endoleaks, migration of the endoprosthesis, and surgical conversion are unique to EVAR. The benefits of EVAR may be less blood loss, shorter hospitalization, and less cardiovascular stress; the risks may be aneurysm recurrence, prolonged surveillance and repeated secondary procedures. The development of EVAR, the complications, and the anesthesia-related concerns of EVAR, including its use in management of acute abdominal aortic aneurysm are reviewed.