Repair of Ruptured Abdominal Aortic Aneurysm in Octogenarians

Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms

OBJECTIVE

The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with aneurysms of the abdominal aorta and iliac arteries in succession to the 2011 and 2019 versions, with the aim of assisting physicians and patients in selecting the best management strategy.

METHODS

The guideline is based on scientific evidence completed with expert opinion on the matter. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to a modified European Society of Cardiology grading system, where the strength (class) of each recommendation is graded from I to III and the letters A to C mark the level of evidence.

RESULTS

A total of 160 recommendations have been issued on the following topics: Service standards, including surgical volume and training; Epidemiology, diagnosis, and screening; Management of patients with small abdominal aortic aneurysm (AAA), including surveillance, cardiovascular risk reduction, and indication for repair; Elective AAA repair, including operative risk assessment, open and endovascular repair, and early complications; Ruptured and symptomatic AAA, including peri-operative management, such as permissive hypotension and use of aortic occlusion balloon, open and endovascular repair, and early complications, such as abdominal compartment syndrome and colonic ischaemia; Long term outcome and follow up after AAA repair, including graft infection, endoleaks and follow up routines; Management of complex AAA, including open and endovascular repair; Management of iliac artery aneurysm, including indication for repair and open and endovascular repair; and Miscellaneous aortic problems, including mycotic, inflammatory, and saccular aortic aneurysm. In addition, Shared decision making is being addressed, with supporting information for patients, and Unresolved issues are discussed.

CONCLUSION

The ESVS Clinical Practice Guidelines provide the most comprehensive, up to date, and unbiased advice to clinicians and patients on the management of abdominal aorto-iliac artery aneurysms.

Predictors of mortality in nonagenarians undergoing abdominal aortic aneurysm repair: analysis of the National Surgical Quality Improvement Program dataset

BACKGROUND

The present study used the American College of Surgeons National Surgical Quality Improvement Program dataset to identify the predictors of 30-day mortality for nonagenarians undergoing endovascular aortic aneurysm repair (EVAR) or open surgical repair (OSR).

METHODS

Patients aged >90 years who had undergone abdominal aortic aneurysm repair from 2005 to 2017 were identified using procedure codes. Those with operative times <15 minutes were excluded. The demographics, preoperative comorbidities, and postoperative complications of those who had died by 30 days were compared with those of the patients alive at 30 days.

RESULTS

A total of 1356 nonagenarians met the criteria: 1229 (90.6%) had undergone EVAR and 127 (9.4%) had undergone OSR. The overall 30-day mortality was 10.4%. The patients who had died within 30 days were significantly more likely to have undergone OSR than EVAR (40.9% vs 7.2%; P < .001). They also had a greater incidence of dependent functional status (22.0% for those who had died vs 8.1% for those alive at 30 days; P < .001), American Society of Anesthesiology (ASA) classification of ≥4 (81.2% vs 18.8%; P < .001), perioperative blood transfusion (59.6% vs 20.3%; P < .001), postoperative pneumonia (12.1% vs 2.9%; P = .001), mechanical ventilation >48 hours (22.7% vs 2.6%; P < .001), and acute renal failure (12.1% vs 0.5%; P < .001). The EVAR group had a 30-day mortality rate of 2.6% in 1008 elective cases and 28.6% in 221 emergent cases. The OSR group had a 30-day mortality rate of 19.1% in 47 elective cases and 53.7% in 80 emergent cases. In the EVAR cohort, the 30-day mortality group had had a significantly greater incidence of dependent functional status (17% for those who had died vs 8% for those alive at 30 days; P = .004), ASA classification of ≥4 (76.4% vs 40.3%; P < .001), perioperative blood transfusion (57% vs 19%; P < .001), emergency surgery (71% vs 14%; P < .001), and longer operative times (150 vs 128 minutes; P = .001).

CONCLUSIONS

Nonagenarians had an incrementally increased, but acceptable, risk of 30-day mortality with EVAR in elective and emergent cases compared with that reported for octogenarians and cohorts of patients not selected for age. We found greater mortality for patients with dependent status, a higher ASA classification, emergent repair, and OSR. These preoperative risk factors could help identify the best surgical candidates. Given these results, consideration for EVAR or OSR might be reasonable for highly selected patients, especially for elective patients with a larger abdominal aortic aneurysm diameter for whom the risk of rupture is higher.

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.

Editor's Choice - Trend-break in Abdominal Aortic Aneurysm Repair With Decreasing Surgical Workload

BACKGROUND

The epidemiology and management of abdominal aortic aneurysms (AAAs) has changed drastically in the past decades, with implementation of nationwide screening programs, introduction of endovascular repair (EVAR), and reduced prevalence of the disease. This report aims to assess recent trends in AAA repair epidemiology in Sweden in this context.

METHODS

Primary AAA repairs registered in the nationwide Swedish Vascular Registry (Swedvasc) 1994-2014 were analyzed regarding patient characteristics, repair incidence, technique, and outcome. Four time periods were compared: 1994-1999, 2000-2004, 2005-2009, and 2010-2014.

RESULT

The incidence of intact AAA repair increased (18.4/100,000 1994-1999, 27.3/100,000 2010-2014, p < .001) predominantly among octogenarians (12.7/100,000 1994-1999, 36.0/100,000 2010-2014, p < .001). The utilization of EVAR increased (58% of all intact AAA repairs 2010-2014), especially among octogenarians (80% 2010-2014). During the last time period, however, the incidence of intact AAA repair stabilized, despite an increasing number of screening-detected AAAs operated on (19% in 2010-2014). Short- and long-term outcome after intact AAA repair continued to improve, most pronounced among octogenarians (30-day mortality 9% 1994-1999, 2% 2010-2014, p < .001). The incidence of ruptured AAA repair steadily decreased (9.2/100,000 1994-1999, 6.9/100,000 2010-2014, p < .001) and the use of EVAR for ruptures increased (30% in 2010-2014). The previously observed improvement of short- and long-term outcome after ruptured AAA repair (30-day mortality 38% 1994-1999, 28% 2010-2014, p < .001) stalled during the last time period. The overall 30-day mortality after ruptured AAA repair was 22% after EVAR versus 31% after open repair in 2010-2014. The corresponding mortality for octogenarians was 28% versus 42%.

CONCLUSIONS

For the first time, a halt in intact AAA repair workload could be identified. This trend-break occurred despite continued increase in treatment of octogenarians and screening-detected aneurysms. Additionally, the ruptured AAA repair incidence continued to decrease. These findings, together with the sustained improvement in survival after AAA repair, may have important impact on planning of vascular surgical services.

Long-term outcome of ruptured abdominal aortic aneurysm: impact of treatment and age

Background

Despite advances in operative repair, ruptured abdominal aortic aneurysm (rAAA) remains associated with high mortality and morbidity rates, especially in elderly patients. The purpose of this study was to evaluate the outcomes of emergency endovascular aneurysm repair (eEVAR), conventional open repair (OPEN), and conservative treatment in elderly patients with rAAA.

Methods

We conducted a retrospective study of all rAAA patients treated with OPEN or eEVAR between January 2005 and December 2011 in the vascular surgery department at Amphia Hospital, the Netherlands. The outcome in patients treated for rAAA by eEVAR or OPEN repair was investigated. Special attention was paid to patients who were admitted and did not receive operative intervention due to serious comorbidity, extremely advanced age, or poor physical condition. We calculated the 30-day rAAA-related mortality for all rAAA patients admitted to our hospital.

Results

Twelve patients did not receive operative emergency repair due to extreme fragility (mean age 87 years, median time to mortality 27 hours). Twenty-three patients had eEVAR and 82 had OPEN surgery. The 30-day mortality rate in operated patients was 30% (7/23) in the eEVAR group versus 26% (21/82) in the OPEN group (P=0.64). No difference in mortality was noted between eEVAR and OPEN over 5 years of follow-up. There were more cardiac adverse events in the OPEN group (n=25, 31%) than in the eEVAR group (n=2, 9%; P=0.035). Reintervention after discharge was more frequent in patients who received eEVAR (35%) than in patients who had OPEN (6%, P<0.001). Advancing age was associated with increasing mortality (hazard ratio 1.05 [95% confidence interval 1.01–1.09]) per year for patients who received operative repair, with a 67%, 76%, and 100% 5-year mortality rate in the 34 patients aged <70 years, 59 patients aged 70–79 years, and 12 octogenarians, respectively; 30-day rAAA-related mortality was also associated with increasing age (21%, 30%, and 61%, respectively; P=0.008).

Conclusion

The 30-day and 5-year mortality in patients who survived rAAA was equal between the treatment options of eEVAR and OPEN. Particularly fragile and very elderly patients did not receive operative repair. The decision to intervene in rAAA should not be made on the basis of patient age alone, but also in relation to comorbidity and patient preference.

Recent risk factors for open surgical mortality in patients with ruptured abdominal aortic aneurysm

Aim

We examined recent relevant prognostic factors for the outcome of open surgical treatment of ruptured abdominal aortic aneurysm.

Methods

Between 2006 and 2012, 35 patients received emergency open surgical treatment for ruptured abdominal aortic aneurysm at our institute. We reviewed ambulance activity logs and clinical records of 34 infrarenal ruptured abdominal aortic aneurysm patients retrospectively. Univariate and multivariate logistic regression analyses were carried out to identify risk factors for surgical outcomes.

Results

Eight patients died during surgery or within a few hours following surgery completion. Through univariate analysis, body mass index, serum lactate level, arterial blood pH, base excess, platelet count, prothrombin time-international normalized ratio, activated partial thromboplastin time, type of ruptured aneurysm, response to i.v. fluid resuscitation within 2,000 mL in the initial therapy, and volume of blood loss during surgery were detected to be significant variants. Multivariate logistic regression analysis revealed the patients who were hemodynamically stabilized after primary volume loading had a 13.2 times higher possibility of survival. Body mass index, high serum lactate level, and volume of blood loss were also found to be independent risk factors of mortality.

Conclusion

The risk factors of open surgical ruptured abdominal aortic aneurysm repair, body mass index, lactate level, volume of intraoperative blood loss, and response to initial 2,000 mL fluid resuscitation were correlated to survival.

Delayed volume resuscitation during initial management of ruptured abdominal aortic aneurysm

OBJECTIVE

In acute traumatic bleeding, permissive arterial hypotension with delayed volume resuscitation is an established lifesaving concept as abridge to surgical control. This study investigated whether preoperatively administered volume also correlated inversely with survival after ruptured abdominal aortic aneurysm (rAAA).

METHODS

This retrospective study analyzed prospectively collected and validated data of a consecutive cohort of patients with rAAAs (January 2001 to December 2010). Generally, fluid resuscitation was guided clinically by the patient's blood pressure and consciousness. All intravenous fluids (crystalloids, colloids, and blood products) administered before aortic clamping or endovascular sealing were abstracted from paramedic and anesthesia documentation and normalized to speed of administration (liters per hour). Logistic regression modeling, adjusted for suspected confounding covariates, was used to investigate whether total volume was independently associated with risk of death within 30 days of rAAA repair.

RESULTS

A total of 248 patients with rAAAs were analyzed, of whom 237 (96%) underwent open repair. A median of 0.91 L of total volume per hour (interquartile range, 0.54-1.50 L/h) had been administered preoperatively to these patients. The postoperative 30-day mortality rate was 15.3% (38 deaths). The preoperative rate of fluid infusion correlated with 30-day mortality after adjustment for confounding factors, and the association persisted robustly through sensitivity analyses: each additional liter per hour increased the odds of perioperative death by 1.57-fold (95% confidence interval, 1.06-2.33; P = .026).

CONCLUSIONS

Aggressive volume resuscitation of patients with rAAAs before proximal aortic control predicted an increased perioperative risk of death, which was independent of systolic blood pressure. Therefore, volume resuscitation should be delayed until surgical control of bleeding is achieved.

Endovascular suitability and outcome after open surgery for ruptured abdominal aortic aneurysm

Background

Endovascular repair of ruptured abdominal aortic aneurysm (rAAA) has rapidly gained popularity, but superior results may be biased by patient selection. The aim was to investigate whether suitability for endovascular repair predicted survival, irrespective of technique of repair.

Methods

Two blinded investigators independently evaluated preoperative computed tomography angiograms of a consecutive cohort of patients with rAAA. Patients were categorized either ‘suitable’ or ‘unsuitable’ for endovascular repair, if assessments agreed. If assessments disagreed, they were classified ‘borderline suitable’. Correlations between endovascular suitability and clinical outcome were adjusted for suspected confounding factors and tested for robustness using sensitivity analyses.

Results

A total of 248 patients with rAAA from January 2001 to December 2010 were included, of whom 237 (95·6 per cent) underwent open repair. Seventy patients (28·2 per cent) were classified as ‘suitable’ and 100 (40·3 per cent) as ‘unsuitable’ for endovascular repair; 63 (25·4 per cent) were considered ‘borderline suitable’. Fifteen (6·0 per cent) could not be assessed and were included in the sensitivity analyses. The postoperative 30-day mortality rate was 15·3 per cent (38 deaths). Multiple logistic regression demonstrated that the odds of perioperative death increased 9·21 (95 per cent confidence interval 2·16 to 39·23) fold for ‘unsuitable’ rAAA (P = 0·003) and 6·80 (1·47 to 31·49) fold for ‘borderline’ rAAA (P = 0·014), compared with ‘suitable’ rAAA. This selection effect was robust across sensitivity analyses and sustained for at least 5 years of follow-up.

Conclusion

Endovascular suitability was an independent and strongly positive predictor of survival after open repair of rAAA.