Prognostic scoring in ruptured abdominal aortic aneurysm: a prospective evaluation

Review of scoring systems for predicting 30-day mortality in ruptured abdominal aortic aneurysm

BACKGROUND

Ruptured abdominal aortic aneurysms (rAAAs) are a serious disease that can lead to high mortality; thus, their early prediction can save patients' lives. The aim of this study was to compare the accuracies of various models for predicting rAAA mortality-including the Glasgow Aneurysm Score (GAS), Vancouver Scoring System (VSS), Dutch Aneurysm Score (DAS), Edinburgh Ruptured Aneurysm Score (ERAS), and Hardman index-based on rAAA treatment outcomes at our institution.

METHODS

Between 2016 and 2022, we retrospectively analyzed the early outcome data-including 30-day mortality-of patients who underwent emergency surgery for rAAA at our institution. Receiver operating characteristic (ROC) curve analysis was performed to compare the aneurysm scoring systems for mortality using the area under the ROC curve (AUC).

RESULTS

The AUC was better for the ERAS (0.718; 95% confidence interval [CI], 0.601-0.817) than for the other scoring systems. Significant differences were observed between ERASs and Hardman indices (difference: 0.179; p=0.016). No significant differences were found among the GAS, VSS, and DAS predictive risk models.

CONCLUSIONS

Among the models for predicting mortality in patients with rAAA, the ERAS model demonstrated the highest AUC value; however, significant differences were only observed between ERASs and Hardman indices. This study may help develop strategies for improving rAAA prediction.

Modified Harborview Risk Score accurately predicts mortality for patients with ruptured abdominal aortic aneurysm

OBJECTIVE

The modified Harborview Risk Score (HRS) is a simple measure initially derived from a single institutional dataset used to predict ruptured abdominal aortic aneurysm (rAAA) repair survival preoperatively using basic labs and vital signs collected upon presentation. However, validation of this widely applicable scoring system has not been performed. This study aims to validate this scoring system using a large multi-institutional database.

METHODS

All patients who underwent repair of an rAAA from 2011 to 2018 in the National Surgical Quality Improvement Program (NSQIP) and at a single academic medical center were included. The modified HRS was calculated by assigning 1 point for each of the following: age >76 years, creatinine >2 mg/dL, international normalized ratio >1.8, and any systolic blood pressure less than 70 mmHg. Assessment of the prediction model was then completed. Using a primary outcome measure of 30-day mortality, the receiver operating characteristic area under the curve was calculated. The discrimination between datasets was compared using a Delong test. Mortality rates for each score were compared between datasets using the Pearson χ2 test. Comparative analysis for patients with a score of 4 was limited due to a small sample size.

RESULTS

A total of 1536 patients were identified using NSQIP, and 163 patients were assessed in the institutional dataset. There were 518 patients with a score of 0 (455 NSQIP, 63 institutional), 676 patients with a score of 1 (617 NSQIP, 59 institutional), 391 patients with a score of 2 (364 NSQIP, 27 institutional), 106 with a score of 3 (93 NSQIP, 13 institutional), and 8 patients with a score of 4 (7 NSQIP, 1 institutional). No difference was found in the receiver operating characteristic area under the curves between datasets (P = .78). Thirty-day mortality was 10% NSQIP vs 22% institutional for a score of 0; 28% NSQIP vs 36% institutional for a score of 1; 41% NSQIP vs 44% institutional for a score of 2; 45% NSQIP vs 69% institutional for a score of 3; and 57% NSQIP vs 100% institutional for a score of 4. Score 0 was the only score with a significant mortality rate difference between datasets (P = .01).

CONCLUSIONS

The modified HRS is confirmed to be broadly applicable as a clinical decision-making tool for patients presenting with rAAAs. Therefore, this easily applicable model should be applied for all patients presenting with rAAAs to assist with provider and patient decision-making prior to proceeding with repair.

Risk Prediction Models for Peri-Operative Mortality in Patients Undergoing Major Vascular Surgery with Particular Focus on Ruptured Abdominal Aortic Aneurysms: A Scoping Review

PURPOSE

The present scoping review aims to describe and analyze available clinical data on the most commonly reported risk prediction indices in vascular surgery for perioperative mortality, with a particular focus on ruptured abdominal aortic aneurysm (rAAA).

MATERIALS AND METHODS

A scoping review following the PRISMA Protocols Extension for Scoping Reviews was performed. Available full-text studies published in English in PubMed, Cochrane and EMBASE databases (last queried, 30 March 2023) were systematically reviewed and analyzed. The Population, Intervention, Comparison, Outcome (PICO) framework used to construct the search strings was the following: in patients with aortic pathologies, in particular rAAA (population), undergoing open or endovascular surgery (intervention), what different risk prediction models exist (comparison), and how well do they predict post-operative mortality (outcomes)?

RESULTS

The literature search and screening of all relevant abstracts revealed a total of 56 studies in the final qualitative synthesis. The main findings of the scoping review, grouped by the risk score that was investigated in the original studies, were synthetized without performing any formal meta-analysis. A total of nine risk scores for major vascular surgery or elective AAA, and 10 scores focusing on rAAA, were identified. Whilst there were several validation studies suggesting that most risk scores performed adequately in the setting of rAAA, none reached 100% accuracy. The Glasgow aneurysm score, ERAS and Vancouver score risk scores were more frequently included in validation studies and were more often used in secondary studies. Unfortunately, the published literature presents a heterogenicity of results in the validation studies comparing the different risk scores. To date, no risk score has been endorsed by any of the vascular surgery societies.

CONCLUSIONS

The use of risk scores in any complex surgery can have multiple advantages, especially when dealing with emergent cases, since they can inform perioperative decision making, patient and family discussions, and post hoc case-mix adjustments. Although a variety of different rAAA risk prediction tools have been published to date, none are superior to others based on this review. The heterogeneity of the variables used in the different scores impairs comparative analysis which represents a major limitation to understanding which risk score may be the "best" in contemporary practice. Future developments in artificial intelligence may further assist surgical decision making in predicting post-operative adverse events.

A Simple Risk Scoring Systems to evaluate the presence of aneurysm and one-year mortality in patients with abdominal aortic aneurysm using CHA2DS2-VASc and ATRIA

OBJECTIVE

We aimed to demonstrate the clinical utility of CHA2DS2-VASc and anticoagulation and risk factors in atrial fibrillation risk scores in the assessment of one year mortality in patients with abdominal aortic aneurysm.

METHODS

We designed a retrospective cohort study using data from Suleyman Demirel University Hospital for the diagnosis of abdominal aortic aneurysm. The study included 120 patients with abdominal aortic aneurysm who underwent aortic computed tomography. Patients were divided into two groups according to presence of abdominal aortic aneurysm and the development of mortality. Predictors of mortality were determined by multiple logistic regression analysis.

RESULTS

Multivariate regression analysis showed that CHA2DS2-VASc score, advanced age, female gender and elevated white blood cell counts were independent predictors of abdominal aortic aneurysm development while CHA2DS2-VASc score and elevated glucose levels were independent predictors of one year mortality in patients with abdominal aortic aneurysm. The concordance statistics for anticoagulation and risk factors in atrial fibrillation risk Score and CHA2DS2-VASc risk score respectively were 0.96 and 0.97 and could significantly predict one year mortality in patients with abdominal aortic aneurysm (p<0.001, and p<0.001, respectively).

CONCLUSIONS

CHA2DS2-VASc and anticoagulation and risk factors in atrial fibrillation risk scores are easily obtained in an emergency setting and can accurately predict one year mortality as a noninvasive follow-up in patients with abdominal aortic aneurysm. These simple scores could be used as a point of care decision aid to help the clinician in counseling patients presenting with abdominal aortic aneurysm and their families on treatment protocols.

Modern mortality risk stratification scores accurately and equally predict real-world postoperative mortality after ruptured abdominal aortic aneurysm

OBJECTIVE

It is often unclear which patients presenting with a ruptured abdominal aortic aneurysm (rAAA) are likely to survive after surgery. The Harborview Medical Center (HMC), Dutch Aneurysm Score (DAS), and Vascular Study Group of New England (VSGNE) risk scores have been recent attempts at predicting mortality in this setting. We compared the prognostic value of these scoring systems for patients at our institution with rAAA.

METHODS

A retrospective chart review was performed for all patients who received surgery at our institution for rAAA between January 1, 2011, and November 27, 2019. The χ², Fisher's exact, and t-tests were used to screen preoperative variables against in-hospital mortality. HMC, DAS, and VSGNE scores were calculated for each patient and tested against in-hospital mortality. Logistic regression and receiver operating characteristic curves were used to assess performance of each scoring system.

RESULTS

Sixty-four patients were identified during the study period. Fifteen patients were excluded because 4 patients chose comfort care and an additional 11 patients were missing key variables. The final cohort for analysis included 49 patients who underwent surgery, including 33 patients receiving endovascular repair and 16 patients receiving open repair. The in-hospital mortality was 37% (24% for endovascular repair vs 63% for open repair). Individual variables associated with in-hospital mortality were lowest preoperative systolic blood pressure (P = .036), creatinine greater than 2.0 mg/dL (P = .020), first recorded intraoperative pH (P = .007), and use of suprarenal aortic control (P = .025), and preoperative cardiac arrest approached significance (P = .051). Plots of the HMC and VSGNE scores vs in-hospital mortality rate produced linear relationships (R² = 0.97 and R² = 0.93, respectively), in which a higher score was associated with a greater likelihood of mortality. On logistic regression analysis using HMC score components, creatinine greater than 2.0 mg/dL produced a significant association with in-hospital mortality (odds ratio, 12.3; 95% confidence interval [CI], 1.1-131.7). Similar analysis using VSGNE components produced a significant association between suprarenal aortic control and in-hospital mortality (odds ratio, 5.5; 95% CI, 1.2-25.5). receiver operating characteristic curves produced an area under the curve of 0.74 (95% CI, 0.60-0.88), 0.73 (95% CI, 0.58-0.87), and 0.67 (95% CI, 0.51-0.83) for the HMC, VSGNE, and DAS, respectively.

CONCLUSIONS

The HMC, VSGNE, and DAS scores performed similarly and adequately predicted in-hospital mortality after rAAA. The HMC score holds the added benefit of using preoperative variables, setting it apart as a valid prognostic indicator in the preoperative setting.

Preoperative risk score for the prediction of mortality after repair of ruptured abdominal aortic aneurysms

OBJECTIVE

Even in the ruptured endovascular aneurysm repair first era, there are still patients who will not survive their ruptured abdominal aortic aneurysm (rAAA). All previously published mortality risk scores include intraoperative variables and are not helpful with the decision to operate or in providing preoperative patient and family counseling. The purpose of this study was to develop a practical preoperative risk score to predict mortality after repair of rAAA.

METHODS

Data of all patients with rAAA presenting between January 1, 2002, and October 31, 2013, were collected. Logistic regression was used to evaluate predictive variables both univariately and jointly, and the results of multivariate models guided the definition of the final simplified scoring algorithm.

RESULTS

There were 303 patients who presented during the study period. Sixteen patients died in the emergency department, en route to surgery, or after choosing comfort care. Preoperative variables most predictive of mortality were age >76 years (odds ratio [OR], 2.11; confidence interval [CI], 1.47-4.97; P = .011), creatinine concentration >2.0 mg/dL (OR, 3.66; CI, 1.85-7.24; P < .001), pH <7.2 (OR, 2.58; CI, 1.27-5.24; P = .009), and systolic blood pressure ever <70 mm Hg (OR, 2.70; CI, 1.46-4.97; P = .002). Assigning 1 point for each variable, patients were stratified according to the preoperative rAAA mortality risk score (range, 0-4). For all repairs, at 30 days, patients with 1 point suffered 22% mortality; 2 points, 69% mortality; and 3 points, 80% mortality. All patients with 4 points died. There was a mortality benefit for ruptured endovascular aneurysm repair across all categories.

CONCLUSIONS

Our rAAA mortality risk score is based on four variables readily assessed in the emergency department and allows accurate prediction of 30-day mortality after repair of rAAAs. It also has a direct impact on clinical decision-making by adding prognostic information to the decision to transfer patients to tertiary care centers and aiding in preoperative discussions with patients and their families.

Evaluation of Preoperative Predictors of 30-Day Mortality in Patients with Ruptured Abdominal Aortic Aneurysm

Purpose

Ruptured abdominal aortic aneurysm (RAAA) is a rare, extremely dangerous condition. Previous studies have published preoperative, intraoperative, and postoperative data; however, there are not enough studies on the preoperative factors alone. Here we studied the preoperative predictors of 30-day mortality in patients with RAAA.

Materials and Methods

We conducted a retrospective, consecutive review of the medical records of 57 patients who received management for RAAA between February 2005 and December 2016. We analyzed the association between preoperative predictors and 30-day mortality in patients with RAAA. The initial systolic blood pressure (SBP) and hemoglobin level (HbL), which were proven as significant predictors by multivariate logistic regression analysis, were compared using receiver operating characteristic curves.

Results

Overall, early mortality was 29.8%. Results of logistic regression analysis found that 30-day mortality in patients with RAAA was associated with the initial SBP (odds ratio [OR], 0.922; 95% confidence interval [CI], 0.874–0.973; P=0.003) and initial HbL (OR, 0.513; 95% CI, 0.289–0.91; P=0.023). Area under the curves were 0.89 for the initial SBP and 0.78 for the initial HbL. The initial SBP with a cut-off value of 90 mmHg had a sensitivity of 85% and specificity of 88.2%. At a cut-off of 10.5, the sensitivity and specificity of HbL for death were 75% and 70.6%, respectively.

Conclusion

The initial SBP and HbL are independent preoperative predictors of early mortality in patients with RAAA.

Systematic review of mortality risk prediction models in the era of endovascular abdominal aortic aneurysm surgery

BACKGROUND

The introduction of endovascular aneurysm repair (EVAR) has reduced perioperative mortality after abdominal aortic aneurysm (AAA) surgery. The objective of this systematic review was to assess existing mortality risk prediction models, and identify which are most useful for patients undergoing AAA repair by either EVAR or open surgical repair.

METHODS

A systematic search of the literature was conducted for perioperative mortality risk prediction models for patients with AAA published since 2006. PRISMA guidelines were used; quality was appraised, and data were extracted and interpreted following the CHARMS guidelines.

RESULTS

Some 3903 studies were identified, of which 27 were selected. A total of 13 risk prediction models have been developed and directly validated. Most models were based on a UK or US population. The best performing models regarding both applicability and discrimination were the perioperative British Aneurysm Repair score (C-statistic 0·83) and the preoperative Vascular Biochemistry and Haematology Outcome Model (C-statistic 0·85), but both lacked substantial external validation.

CONCLUSION

Mortality risk prediction in AAA surgery has been modelled extensively, but many of these models are weak methodologically and have highly variable performance across different populations. New models are unlikely to be helpful; instead case-mix correction should be modelled and adapted to the population of interest using the relevant mortality predictors.

High proportion of known abdominal aortic aneurysm in patients with rupture indicates surveillance deficiency

OBJECTIVE

This study assessed the proportion of previously known abdominal aortic aneurysm (AAA) in patients presenting with a ruptured AAA (rAAA) and analyzed the reasons for nontreatment at the time of the initial AAA diagnosis.

METHODS

This retrospective, observational study included all patients with rAAA admitted to a hospital in the counties of Stockholm and Gotland during 2009 to 2013. The patients' records were retrospectively reviewed, with extraction of data on previously detected AAA, demographics, and mortality at 30 and 90 days.

RESULTS

We identified 283 patients (76% men) with a mean age of 78.7 years. An AAA had been previously detected in 85 (30%). The overall mortality was higher (68% vs 53%; P = .018) and the intervention rate was lower in patients with a previously detected AAA (59% vs 82%, P < .001). The 90-day mortality rate for all treated rAAA was 43%. Reasons for nontreatment at the initial AAA detection were denial of elective surgery in 31 (36%), patient choice in 15 (18%), size-related in 11 (13%), and surveillance deficiency in 26 (31%). The latter group included patients who failed to comply, missed referral for computed tomography scans, and lack of follow-up of radiology reports. At the time of rupture, 22 patients (85%) were treated, with 30-day and 90-day mortality rates both at 41% (n = 9).

CONCLUSIONS

One-third of patients admitted with a rAAA had a previously detected AAA. The surgeons' decision to deny elective surgery and surveillance deficiency were the two main reasons for nontreatment at time of the AAA diagnosis. Improved patient-specific protocols to reduce the surveillance gaps and new methods of determining rupture risk in each case of AAA could be two possible future strategies to reduce the incidence of rupture.

Prediction of in-hospital mortality after ruptured abdominal aortic aneurysm repair using an artificial neural network

OBJECTIVE

Ruptured abdominal aortic aneurysm (rAAA) carries a high mortality rate, even with prompt transfer to a medical center. An artificial neural network (ANN) is a computational model that improves predictive ability through pattern recognition while continually adapting to new input data. The goal of this study was to effectively use ANN modeling to provide vascular surgeons a discriminant adjunct to assess the likelihood of in-hospital mortality on a pending rAAA admission using easily obtainable patient information from the field.

METHODS

Of 332 total patients from a single institution from 1998 to 2013 who had attempted rAAA repair, 125 were reviewed for preoperative factors associated with in-hospital mortality; 108 patients received an open operation, and 17 patients received endovascular repair. Five variables were found significant on multivariate analysis (P < .05), and four of these five (preoperative shock, loss of consciousness, cardiac arrest, and age) were modeled by multiple logistic regression and an ANN. These predictive models were compared against the Glasgow Aneurysm Score. All models were assessed by generation of receiver operating characteristic curves and actual vs predicted outcomes plots, with area under the curve and Pearson r(2) value as the primary measures of discriminant ability.

RESULTS

Of the 125 patients, 53 (42%) did not survive to discharge. Five preoperative factors were significant (P < .05) independent predictors of in-hospital mortality in multivariate analysis: advanced age, renal disease, loss of consciousness, cardiac arrest, and shock, although renal disease was excluded from the models. The sequential accumulation of zero to four of these risk factors progressively increased overall mortality rate, from 11% to 16% to 44% to 76% to 89% (age ≥ 70 years considered a risk factor). Algorithms derived from multiple logistic regression, ANN, and Glasgow Aneurysm Score models generated area under the curve values of 0.85 ± 0.04, 0.88 ± 0.04 (training set), and 0.77 ± 0.06 and Pearson r(2) values of .36, .52 and .17, respectively. The ANN model represented the most discriminant of the three.

CONCLUSIONS

An ANN-based predictive model may represent a simple, useful, and highly discriminant adjunct to the vascular surgeon in accurately identifying those patients who may carry a high mortality risk from attempted repair of rAAA, using only easily definable preoperative variables. Although still requiring external validation, our model is available for demonstration at https://redcap.vanderbilt.edu/surveys/?s=NN97NM7DTK.

Early prediction of survival after open surgical repair of ruptured abdominal aortic aneurysms

Background

Scoring models are widely established in the intensive care unit (ICU). However, the importance in patients with ruptured abdominal aortic aneurysm (RAAA) remains unclear. Our aim was to analyze scoring systems as predictors of survival in patients undergoing open surgical repair (OSR) for RAAA.

Methods

This is a retrospective study in critically ill patients in a surgical ICU at a university hospital. Sixty-eight patients with RAAA were treated between February 2005 and June 2013. Serial measurements of Sequential Organ Failure Assessment score (SOFA), Simplified Acute Physiology Score II (SAPS II) and Simplified Therapeutic Intervention Scoring System-28 (TISS-28) were evaluated with respect to in-hospital mortality. Eleven patients had to be excluded from this study because 6 underwent endovascular repair and 5 died before they could be admitted to the ICU.

Results

All patients underwent OSR. The initial, highest, and mean of SOFA and SAPS II scores correlated significant with in-hospital mortality. In contrast, TISS-28 was inferior and showed a smaller area under the receiver operating curve. The cut-off point for SOFA showed the best performance in terms of sensitivity and specificity. An initial SOFA score below 9 predicted an in-hospital mortality of 16.2% (95% CI, 4.3–28.1) and a score above 9 predicted an in-hospital mortality of 73.7% (95% CI, 53.8–93.5, p < 0.01). Trend analysis showed the largest effect on SAPS II. When the score increased or was unchanged within the first 48 h (score >45), the in-hospital mortality rate was 85.7% (95% CI, 67.4–100, p < 0.01) versus 31.6% (95% CI, 10.7–52.5, p = 0.01) when it decreased. On multiple regression analysis, only the mean of the SOFA score showed a significant predictive capacity with regards to mortality (odds ratio 1.77; 95% CI, 1.19–2.64; p < 0.01).

Conclusion

SOFA and SAPS II scores were able to predict in-hospital mortality in RAAA within 48 h after OSR. According to cut-off points, an increase or decrease in SOFA and SAPS II scores improved sensitivity and specificity.

Derivation and validation of a practical risk score for prediction of mortality after open repair of ruptured abdominal aortic aneurysms in a US regional cohort and comparison to existing scoring systems

OBJECTIVE

Scoring systems for predicting mortality after repair of ruptured abdominal aortic aneurysms (RAAAs) have not been developed or tested in a United States population and may not be accurate in the endovascular era. Using prospectively collected data from the Vascular Study Group of New England (VSGNE), we developed a practical risk score for in-hospital mortality after open repair of RAAAs and compared its performance to that of the Glasgow aneurysm score, Hardman index, Vancouver score, and Edinburg ruptured aneurysm score.

METHODS

Univariate analysis followed by multivariable analysis of patient, prehospital, anatomic, and procedural characteristics identified significant predictors of in-hospital mortality. Integer points were derived from the odds ratio (OR) for mortality based on each independent predictor in order to generate a VSGNE RAAA risk score, which was internally validated using bootstrapping methodology. Discrimination and calibration of all models were assessed by calculating the area under the receiver-operating characteristic curve (C-statistic) and applying the Hosmer-Lemeshow test.

RESULTS

From 2003 to 2009, 242 patients underwent open repair of RAAAs at 10 centers. In-hospital mortality was 38% (n = 91). Independent predictors of mortality included age >76 years (OR, 5.3; 95% confidence interval [CI], 2.8-10.1), preoperative cardiac arrest (OR, 4.3; 95% CI, 1.6-12), loss of consciousness (OR, 2.6; 95% CI, 1.2-6), and suprarenal aortic clamp (OR, 2.4; 95% CI, 1.3-4.6). Patient stratification according to the VSGNE RAAA risk score (range, 0-6) accurately predicted mortality and identified those at low and high risk for death (8%, 25%, 37%, 60%, 80%, and 87% for scores of 0, 1, 2, 3, 4, and ≥5, respectively). Discrimination (C = .79) and calibration (χ(2) = 1.96; P = .85) were excellent in the derivation and bootstrap samples and superior to that of existing scoring systems. The Glasgow aneurysm score, Hardman index, Vancouver score, and Edinburg ruptured aneurysm score correlated with mortality in the VSGNE cohort but failed to identify accurately patients with a risk of mortality >65%.

CONCLUSIONS

Existing scoring systems predict mortality after RAAA repair in this cohort but do not identify patients at highest risk. This parsimonious VSGNE RAAA risk score based on four variables readily assessed at the time of presentation allows accurate prediction of in-hospital mortality after open repair of RAAAs, including identification of those patients at highest risk for postoperative mortality.

Preoperative risk factors for in-hospital mortality and validity of the Glasgow aneurysm score and Hardman index in patients with ruptured abdominal aortic aneurysm

The aim of this study is to evaluate the validity of the Glasgow aneurysm score (GAS) and Hardman index in patients operated on because of ruptured abdominal aortic aneurysm (rAAA), and determining preoperative risk factors that affect in-hospital mortality. One hundred one patients operated on to repair a rAAA within the last 10 years were included. The GAS and Hardman index were calculated for each patient separately. The relation between in-hospital mortality and the Hardman index and GAS was analyzed by means of the receiver-operator characteristic (ROC) curve. Univariate and multivariate methods of analyses were used to determine preoperative risk factors. Average age was 69 ± 8, and in-hospital mortality rate was 51.5%. Analysis of the ROC curve showed that the Hardman index had an area under the curve (AUC) = 0.71 (95% confidence interval [CI], 0.593–0.800, P = 0.0002) for predicting in-hospital mortality. The GAS had an AUC = 0.77 (95% CI, 0.680–0.851, P < 0.0001). The results of multivariate analysis revealed the presence of the following preoperative risk factors: age more than 63 years (odds ratio [OR], 4.4; 95% CI, 1.17–16.49, P = 0.028); loss of consciousness (OR, 9.33; 95% CI, 1.94–44.86, P = 0.005); creatinine higher than 1.7 mg/dL (OR, 5.52; 95% CI, 1.92–15.85, P = 0.001); and pH lower than 7.31 (OR, 3.77; 95% CI, 1.18–11.99, P = 0.024). In conclusion, the Hardman index and GAS have a significant correlation with in-hospital mortality rates. Nevertheless, a high score does not necessarily correspond with a definite mortality. This is why scoring systems could not be considered as the sole criterion for choosing patients for this study. Clinical experience was still the leading factor in deciding against or in favor of surgery.

My Patient Has No Blood Pressure: Have They Got an Abdominal Aortic Aneurysm? Point-Of-Care Ultrasound of the Abdominal Aorta in Hypotensive Patients

Among patients presenting to the emergency department (ED) with undifferentiated hypotension, how can point-of-care ultrasound (PoCUS) help identify abdominal aortic aneurysm (AAA) as the cause of the hypotension? Many hypotensive patients in the ED are critically ill, with only minutes available to find the cause of the hypotension and treat it before the patient decompensates. While the classic description of the presentation of a ruptured AAA is of collapse with sudden onset abdominal pain and a palpable, pulsatile abdominal mass, detection of AAA by palpation is notoriously unreliable, and many patients are unaware of their underlying condition. This life-threatening situation is made even more difficult by virtue of the fact that the patient is often too unstable to travel for traditional diagnostics such as computed tomography. This article will address the use of PoCUS for the detection of AAA in the evaluation of the hypotensive patient.

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.

Routine screening for asymptomatic abdominal aortic aneurysm in high-risk patients is not recommended in emergency departments that are frequently crowded

OBJECTIVES

The objectives were to examine the feasibility of offering abdominal aortic aneurysm (AAA) screening to consecutive, asymptomatic high-risk patients in a busy emergency department (ED) and to compare the prevalence of undetected AAA among ED patients to the prevalence among similarly aged men from the general population.

METHODS

A prospective cohort study was conducted at an academic community ED with an annual census of 58,000 patients. Dedicated study coordinators attempted to approach all consecutive male ED patients >50 years who presented in June-August 2007 during hours of high patient volume. To be eligible, older males had to have a smoking history or a family history of AAA. Patients were excluded if they presented with AAA symptoms, had a previous history of AAA screening or repair, had hemodynamic instability, or had an altered mental status. Study coordinators completed a brief interview with all enrolled subjects to obtain demographic and health information. A credentialed ED provider performed the ultrasound (US) screening exam and documented all findings. The US director reviewed representative images of the sonographic exam for correct visualization and measurement during quality assurance. The ED sonographers also completed a survey regarding their attitudes toward AAA screening in the ED. The primary study outcomes were the feasibility of AAA screening in the ED (screening rate, enrollment rate, US success rate, and providers' opinions) and the prevalence of AAA (aortic diameter of > or =3.0 cm) in the study sample.

RESULTS

During the 12-week study period, the study coordinators successfully approached 96% (700/729) of males > 50 years who were in the ED during study enrollment hours. Of those approached, 278 were eligible (40%), 25% were ineligible, 20% were not at high risk, and for 15% we could not determine risk factor status because of altered mental status. Of the 278 eligible, 196 (70%) underwent an US exam; 10% were not scanned because the providers were too busy, and 20% declined participation. Of those scanned, the ED sonographer was able to completely visualize and correctly measure the abdominal aortas of 71% of subjects. The prevalence rate of AAA in the study sample was 5.7% (95% confidence interval [CI] = 1.9% to 9.6%), similar to reported rates of 6 or 7% in other studies. More than half of the ED sonographers reported that US screening for AAA improved the quality of ED care (58%) and patient satisfaction (63%). However, 47% reported that AAA screening reduced ED efficiency, and 74% felt that the ED was not an appropriate setting for routine AAA screening.

CONCLUSIONS

Routine screening for asymptomatic AAA required substantial ED resources for a relatively low success rate of completed screens. The prevalence rate of AAA in our ED sample was not significantly different than prevalence estimates obtained from older men in the general population. ED sonographers reported benefits of screening in terms of improving the quality of emergency care and patient satisfaction, but also reported that it reduced operational efficiency. For EDs that have problems with crowding, we do not recommend implementing a routine screening program for AAA, even among high-risk patients.

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.

Open repair for ruptured abdominal aortic aneurysm: is it possible to predict survival?

The aim of the study was to determine variables that could be used to predict survival in patients with ruptured abdominal aortic aneurysm (RAAA) and to assess the accuracy of the Glasgow Aneurysm Score (GAS) and the Acute Physiology Chronic Health Evaluation II (APACHE-II). From January 1998 to July 2006, 103 patients underwent operations for RAAA. For each patient, 44 variables were retrospectively recorded in a database. Data were analyzed with univariate and multivariate methods. In the univariate analysis significant predictors of death were hypotension (p=0.001), preexisting peripheral vascular disease (p<0.001), renal insufficiency (p=0.037), chronic obstructive pulmonary disease (p=0.028), level of HCO(3)(-) (p<0.001), intraperitoneal rupture (p=0.001), blood transfused (p<0.001), cardiac complications (p<0.001), and APACHE-II score (p=0.001). Multivariate analysis confirmed statistical significance for coexisting peripheral vascular disease (p<0.001), diastolic blood pressure at admission <60 mm Hg (p=0.039), APACHE-II score >18.5 (p=0.025), HCO(3)(-) <21 mg/dL (p<0.001), and intraperitoneal rupture of the aneurysm (p=0.011) as predictors of death. Results of the study suggested that different factors can be helpful in identifying those patients whose operative risk is prohibitive. APACHE-II, contrary to GAS, is an accurate system to predict postoperative death after repair for RAAA.