Factors increasing the mortality rate for patients with ruptured abdominal aortic aneurysms

Derivation and Validation of a Risk Score for Abdominal Compartment Syndrome after Endovascular Aneurysm Repair for Ruptured Abdominal Aortic Aneurysms

BACKGROUND

Abdominal compartment syndrome (ACoS) is a devastating complication after endovascular aneurysm repair for ruptured abdominal aortic aneurysms (rEVAR). This study sought to develop a risk score for ACoS to identify patients who would benefit from early decompressive laparotomy.

METHODS

Model derivation was performed with VQI data for rEVAR from 2013-2020. The primary outcome was evacuation of abdominal hematoma. Multivariable logistic regression was used to create and validate a scoring system to predict ACoS. The model was validated using institutional data for rEVAR from 1998-2019.

RESULTS

The derivation cohort included 2,310 patients with rEVAR. Abdominal hematoma evacuation occurred in 265 patients (11.5%). Factors associated with abdominal hematoma evacuation on multivariable analysis included transfer from an outside hospital, preoperative creatinine ≥1.4 mg/dl, preoperative systolic blood pressure ≤85 mmHg, preoperative altered mental status, ≥3.0 liters intraoperative crystalloid, and ≥4 units of red blood cells transfused intraoperatively. The validation cohort consisted of 67 rEVAR; ACoS occurred in 8 patients (11.9%). The c-statistic was 0.84 in the derivation and 0.87 in the validation cohort, while Hosmer-Lemeshow was p= 0.15 in the derivation and 0.84 in the validation cohorts, suggesting good model discrimination and calibration. Points were applied based on β-coefficients to produce a risk score ranging from -1 to 13. A cutoff of risk score ≥8 resulted in a sensitivity and specificity of 87.5% and 83.1% for detecting patients with ACoS, respectively. ACoS conveyed a significantly higher mortality in both the derivation (ACoS: 49.8% vs No ACoS: 17.8%; p<0.001) and validation cohorts (ACoS: 75.0% vs No ACoS: 15.2%; p<0.001).

CONCLUSION

In patients with equivocal signs/symptoms of ACoS, this scoring system can be used to guide surgeons on when to perform decompressive laparotomy prior to leaving the operating room for rEVAR. Patients with a risk score ≥8 would benefit from decompressive laparotomy at index rEVAR.

Hypotension after intensive care unit drop-off in adult cardiac surgery patients

BACKGROUND

Hypotension is a frequent complication in the intensive care unit (ICU) after adult cardiac surgery.

AIM

To describe frequency of hypotension in the ICU following adult cardiac surgery and its relation to the hospital outcomes.

METHODS

A retrospective study of post-cardiac adult surgical patients at a tertiary academic medical center in a two-year period. We abstracted baseline demographics, comorbidities, and all pertinent clinical variables. The primary predictor variable was the development of hypotension within the first 30 min upon arrival to the ICU from the operating room (OR). The primary outcome was hospital mortality, and other outcomes included duration of mechanical ventilation (MV) in hours, and ICU and hospital length of stay in days.

RESULTS

Of 417 patients, more than half (54%) experienced hypotension within 30 min upon arrival to the ICU. Presence of OR hypotension immediately prior to ICU transfer was significantly associated with ICU hypotension (odds ratio = 1.9; 95% confidence interval: 1.21-2.98; P < 0.006). ICU hypotensive patients had longer MV, 5 (interquartile ranges 3, 15) vs 4 h (interquartile ranges 3, 6), P = 0.012. The patients who received vasopressor boluses (n = 212) were more likely to experience ICU drop-off hypotension (odds ratio = 1.45, 95% confidence interval: 0.98-2.13; P = 0.062), and they experienced longer MV, ICU and hospital length of stay (P < 0.001, for all).

CONCLUSION

Hypotension upon anesthesia-to-ICU drop-off is more frequent than previously reported and may be associated with adverse clinical outcomes.

Perioperative, Postoperative, and Long-Term Outcomes Following Open Surgical Repair of Ruptured Abdominal Aortic Aneurysm

We investigated factors that affected perioperative, postoperative, and long-term outcomes of patients who underwent open emergency surgical repair of ruptured abdominal aortic aneurysms (RAAA). All patients who underwent open emergency surgical repair from 1990 to 2011 were included (463 patients; 374 [81%] male; mean age 74.7 ± 8.7years). Logistic and Cox regression analyses were performed to explore the association of variables with outcomes. Preoperatively, median (interquartile range) hemoglobin was 11.2 (9.5-12.8) g/dL, and median creatinine level was 140 (112-177) µmol/L. Intraoperatively, the median operative time was 2.25 (2-3) hours, and median estimated blood loss was 1.5 (0.5-3) L; 250 (54%) patients required intraoperative inotropes, and a median of 6 (4-8) units of blood was transfused. Median length of hospital stay was 11 (7-20) days. In-hospital mortality rate was 35.6%, and 5-year mortality was 48%. Age, distance traveled, operation duration, postoperative myocardial infarction (MI), and multi-organ failure (MOF) were predictors of in-hospital mortality and long-term outcome. Additionally, postoperative acute renal failure predicted in-hospital mortality. In patients with RAAA undergoing open surgical repair, the strongest predictors of in-hospital mortality and long-term outcome were postoperative MOF and MI and operative duration.

Mortality rates and risk factors for emergent open repair of abdominal aortic aneurysms in the endovascular era

The background of this paper is to report the mortality at 30 and 90 days and at mean follow-up after open abdominal aortic aneurysms (AAA) emergent repair and to identify predictive risk factors for 30- and 90-day mortality. Between 1997 and 2002, 104 patients underwent emergent AAA open surgery. Symptomatic and ruptured AAAs were observed, respectively, in 21 and 79% of cases. Mean patient age was 70 (SD 9.2) years. Mean aneurysm maximal diameter was 7.4 (SD 1.6) cm. Primary endpoints were 30- and 90-day mortality. Significant mortality-related risk factor identification was the secondary endpoint. Open repair trend and its related perioperative mortality with a per-year analysis and a correlation subanalysis to identify predictive mortality factor were performed. Mean follow-up time was 23 (SD 23) months. Overall, 30-day mortality was 30%. Significant mortality-related risk factors were the use of computed tomography (CT) as a preoperative diagnostic tool, AAA rupture, preoperative shock, intraoperative cardiopulmonary resuscitation (CPR), use of aortic balloon occlusion, intraoperative massive blood transfusion (MBT), and development of abdominal compartment syndrome (ACS). Previous abdominal surgery was identified as a protective risk factor. The mortality rate at 90 days was 44%. Significant mortality-related risk factors were AAA rupture, aortocaval fistula, peripheral artery disease (PAD), preoperative shock, CPR, MBT, and ACS. The mortality rate at follow-up was 45%. Correlation analysis showed that MBT, shock, and ACS are the most relevant predictive mortality factor at 30 and 90 days. During the transition period from open to endovascular repair, open repair mortality outcomes remained comparable with other contemporary data despite a selection bias for higher risk patients. MBT, shock, and ACS are the most pronounced predictive mortality risk factors.

Long-term outcome and quality of life after ruptured abdominal aortic aneurysm repair

Objectives

To evaluate long-term outcome and quality of life after open and endovascular repair of ruptured abdominal aortic aneurysms.

Methods

All consecutive ruptured abdominal aortic aneurysm patients at the St. Antonius Hospital treated for ruptured abdominal aortic aneurysm between January 2005 and January 2015 were included. Mortality, morbidity, and re-interventions within 30 days and during follow-up were registered. Quality of life was measured with Short Form-36 questionnaire among survivors. Additional subgroup analysis between open repair and endovascular repair was performed.

Results

A total of 192 patients with ruptured abdominal aortic aneurysm were included: 76.6% (147/192) underwent open repair and 23.4% (45/192) endovascular repair. All-cause 30-day mortality rate was 31.3% (60/192), and 30-day morbidity rate was 70.3% (135/192). Median stay at the intensive care unit was two days for endovascular repair and four days for open repair ( p = 0.002). No other statistically significant differences between endovascular repair and open repair were observed. After a mean follow-up period of 62 months (range 9–126), 72.4% (76/105) of the responders had equivalent Short Form-36 scores as compared to the age-matched general Dutch population, and 84.2% (64/76) of the responders would choose surgery again if they would have a ruptured abdominal aortic aneurysm.

Conclusions

Survivors of ruptured abdominal aortic aneurysm have similar long-term quality of life scores compared to the age-matched general population. The majority of all survivors would choose to undergo acute abdominal aortic aneurysm repair again.

Factors affecting the postoperative mortality in the ruptured abdominal aortic aneurysm

Background

Although patients with a ruptured abdominal aortic aneurysm (RAAA) often reach the hospital alive, the perioperative mortality is still very high. We retrospectively reviewed thirty patients who underwent repair of RAAA to identify the factors affecting postoperative mortality in a single hospital.

Materials and Methods

Between September 2007 and May 2011, thirty patients with RAAA underwent emergent surgery (n=27) or endovascular aneurysm repair (n=3). Their medical records were retrospectively reviewed regarding three categories: 1) preoperative patient status: age, gender, vital signs, serum creatinine, blood urea nitrogen, hematocrit, and hemoglobin level: 2) aneurysmal status: size, type, and rupture status; and 3) operative factors: interval time to operating room, operative duration, and amount of perioperative transfusion.

Results

The 30-day postoperative mortality rate was 13.3% (4/30); later mortality was 3.3% (1/30). On multivariate analysis, the initial diastolic blood pressure (BP), interval time to operating room and amount of preoperative packed cell transfusion were statistically significantly linked with postoperative mortality (p<0.05).

Conclusion

In this study, preoperative diastolic BP, preoperative packed cell transfusion amount and interval time between arrival and entry to operating room were significantly associated with postoperative mortality. It is important to prevent hemorrhage as quickly as possible.

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.

Prediction of outcome after abdominal aortic aneurysm rupture

BACKGROUND

Most vascular surgeons practice a selective policy of operative intervention for patients with ruptured abdominal aortic aneurysm (AAA). The evidence on which to justify operative selection remains uncertain. This review examines the prediction of outcome after attempted open repair of ruptured AAA.

METHODS

The Medline and EMBASE databases and Cochrane Database of Systematic Reviews were searched for clinical studies relating to the prediction of outcome after ruptured AAA. Reference lists of relevant articles were also reviewed.

RESULTS

The last 20 years has seen >60 publications considering variables predictive of outcome after AAA rupture. Four predictive scoring systems are reported: Hardman Index, Glasgow Aneurysm Score, Physiological and Operative Severity Score for Enumeration of Mortality and Morbidity (POSSUM), and the Vancouver Scoring System. No scoring system has been shown to have consistent or absolute validity. Of the remaining data, there are no individual or combination of variables that can accurately and consistently predict outcome.

CONCLUSIONS

Little robust evidence is available on which to base preoperative outcome prediction in patients with ruptured AAA. Experienced clinical judgement will remain of foremost importance in the selection of patients for ruptured AAA repair.

Validity of the Hardman Index to Predict Outcome in Ruptured Abdominal Aortic Aneurysm

This study assessed the validity of the Hardman index in predicting outcome following open repair of ruptured abdominal aortic aneurysm and whether this scoring system can be used reliably to select patients for surgical repair. Patients undergoing open repair of ruptured abdominal aortic aneurysm in two university teaching hospitals over a 5-year period were identified from a computerized hospital database. Thirty-day mortality was the main outcome measure. Five Hardman index factors were calculated and related to outcome retrospectively. There were 178 patients with a mean age of 73.9 years (range 51-94) and a male to female ratio of 5.4:1. The overall in-hospital mortality was 57.3% (102/178). Univariate analysis of risk factors showed that age >76 years (P = 0.007, odds ratio [OR] 2.34, 95% confidence interval [CI] 1.26-4.37) and electrocardiograghic evidence of ischemia on admission (P = 0.002, OR 3.75, 95% CI 1.57-8.93) were associated with high mortality. However, loss of consciousness (P = 0.155, OR 1.56, 95% CI 0.85-2.86), hemoglobin <9 g/dL (P = 0.118, OR 1.89, 95% CI 0.85-4.22), and serum creatinine >0.19 mmol/L (P = 0.691, OR 1.25, 95% CI 0.42-3.70) were not significant predictors of mortality. Using a multivariate analysis, age >76 years (P = 0.043, OR 2.29, 95% CI 1.03-5.11) and myocardial ischemia (P = 0.029, OR 2.93, 95% CI 1.12-7.67) were again found to be the significant predictors of mortality. The operative mortality was 44%, 46%, 68%, 79%, and 100% for Hardman scores of 0, 1, 2, 3, and 4, respectively. No patient had a score of 5. The Hardman index is not a reliable predictor of outcome following repair of ruptured abdominal aortic aneurysm. High-risk patients may still survive and should not be denied surgical repair based on the scoring system alone. Further evaluation of the risk factors is required to reliably and justifiably exclude those patients in whom the intervention is inappropriate.

Improvement of Mortality of Ruptured Abdominal Aortic Aneurysm Patients over 12 Years and Its Relationship with Tracheostomy

Cardiopulmonary complication after ruptured abdominal aortic aneurysm (rAAA) repair is an important cause of mortality. Early tracheostomy promotes patient recovery from respiratory morbidities. A policy of routine immediate tracheostomy was adopted in 1999 at our institution. This study investigates the trend of hospital mortality of rAAA patients over 12 years with particular reference to immediate tracheostomy. Consecutive rAAA patients operated during 1993-2004 were divided into two groups (first group, 1993-1998; second group, 1999-2002). Intra- and postoperative care was the same for all patients except that immediate tracheostomy was performed routinely in the second group and only selectively in the first. Hospital mortality of the two groups was examined. Patient characteristics, biochemical parameters, aneurysm feature, operative details, and clinical outcomes of the two groups (excluding 48 hr perioperative mortalities) were compared to identify prognostic factors of hospital mortality. Sixty-three patients were operated during the study period. The overall hospital mortality for the first and second groups was 62.5% (20/32) and 22.6% (7/31) (p=0.001), respectively. Excluding the 48 hr mortalities, 57.1% (12, n=21) of patients in the first group and 85.7% (24, n=28) of those in the second group survived to be discharged from hospital (p=0.048). The pre-, intra-, and postoperative parameters were comparable between the two groups. Immediate tracheostomy was performed for all patients in the second group and only 52.4% (11) in the first group. Male gender, high creatinine level on presentation, postoperation cardiac morbidity, renal failure, and bowel ischemia were found to be associated with a higher mortality. Immediate tracheostomy is a significant factor associated with improved survival. In conclusion, a significant improvement of rAAA patients' in-hospital mortality was achieved during the study period. Tracheostomy performed immediately following rAAA repair is associated with better hospital survival.

The Management of Abdominal Aortic Aneurysms in Patients with Concurrent Renal Impairment

INTRODUCTION

Patients with concurrent renal impairment and abdominal aortic aneurysms present a significant challenge in terms of pre-operative, intra-operative and post-operative management. This aim of this review was to determine the risks of surgery in this patient group and determine whether any clear management strategies exist to enhance their clinical management.

METHODS

Systematic review of published literature giving details of the outcome of open or endovascular abdominal aortic aneurysm repair in patients with pre-operative renal impairment. Papers concerning the management of post-operative acute renal failure in patients with normal pre-operative renal function has not been included.

RESULTS

There is little data regarding patients with end-stage renal failure and AAA although these patients appear to have a high peri-operative mortality rate. In contrast, those with renal impairment do not have a significantly higher mortality rate than those with normal renal function, rather they have a higher risk of complications associated with surgery and may require more intensive post-operative organ system support than normal patients. Many have a transient deterioration in renal function in the immediate peri-operative period that will resolve. In the case of patients with ruptured AAA, it is not clear whether pre-operative renal impairment affects mortality.

Lifetime Gain Related to Cost of Repair of Ruptured Abdominal Aortic Aneurysm in Octogenarians

OBJECTIVE

To report cost related to gained life years after repair of ruptured abdominal aortic aneurysms in patients aged 80 or older.

DESIGN

A retrospective study based on prospectively registered data.

PATIENTS AND METHODS

Fifty-three patients aged 80 or older were operated on for ruptured abdominal aortic aneurysm over a 20-year period from 1983 to 2002. Thirty-one (58%) patients had systolic BT <80 mmHg. Operative mortality (<30 days) and long-term survival were studied. The number of life-years gained from the operations was estimated. Based on diagnose related group (DRG) values, the cost of each gained life-year was calculated.

RESULTS

The operative mortality was 47%. Long-term survival of those patients who survived the operation was similar to that of an age and sex matched population. The 53 operations resulted in 145 gained life-years, which leaves a mean survival of 2.7 years of all the patients and 5.2 years of those who survived the operation. The estimated cost per gained life year was euro6817.

CONCLUSIONS

The operative mortality of ruptured abdominal aortic aneurysm remains high. The long-term survival of patients who survive the operation is acceptable. The price of each gained life-year is low, as compared to other established treatment modalities. Improved results with endovascular treatment may even decrease the cost per gained life year.

CT of acute abdominal aortic disorders

Aortic aneurysm rupture, aortic dissection, PAU, acute aortic occlusion, traumatic aortic injury, and aortic fistula represent acute abdominal aortic conditions. Because of its speed and proximity to the emergency department, helical CT is the imaging test of choice for these conditions. MR imaging also plays an important role in the imaging of aortic dissection and PAU, particularly when the patient is unable to receive intravenous contrast material. In this era of MDCT, conventional angiography is used as a secondary diagnostic tool to clarify equivocal findings on cross-sectional imaging. Ultrasound is helpful when CT is not readily available and the patient is unable or too unstable to undergo MR imaging.

A CUSUM analysis of ruptured abdominal aortic aneurysm repair

Studies have investigated the role of hospital and surgeon case volume in outcome after ruptured abdominal aortic aneurysm repair (rAAA). Few have analyzed the learning curve of an individual surgeon. The purpose of this study was to analyze this learning curve in reducing morbidity and mortality after rAAA repair. Thirty-two consecutive patients who underwent rAAA repair during the initial 2.5 years of a vascular surgeon's career were reviewed retrospectively. They were divided temporally into two groups of 16 patients (groups 1 and 2). Outcome measures included mortality, postoperative myocardial infarction, stroke, and renal and respiratory failure. Perioperative variables previously associated with increased mortality were analyzed. The cumulative sum (CUSUM) method was used to analyze the learning curve with respect to published acceptable event rates and predetermined 80% alert and 95% alarm boundary lines. Groups 1 and 2 did not differ statistically in age, preoperative blood pressure, hemoglobin or creatinine. There was no difference in transfusion requirements (6.8 +/- 1.2 units vs. 6.4 +/- 1.0 units; p = 0.78), urine output (340 +/- 65 mL vs. 389 +/- 94 mL; p = 0.72) or clamp position. There was no difference in the incidence of postoperative myocardial infarction, stroke, or respiratory or renal failure. Thirty-day mortality in group 2 was 12% as compared to 50% in Group 1 (p = 0.03). On CUSUM analysis, the cumulative failure rate in group 2 progressed lower than the 80% reassurance line, indicating improved results with time. Mortality after rAAA repair decreased over time during an early period of an individual surgeon's career. The CUSUM method is a valuable tool in analyzing an individual surgeon's experience and shows promise in quality control in vascular surgery.