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Li SR, Phillips AR, Reitz KM, Mikati N, Brown JB, Tzeng E, Makaroun MS, Guyette FX, Liang NL. Hypertension during transfer is associated with poor outcomes in unstable patients with ruptured abdominal aortic aneurysm. J Vasc Surg 2024; 79:755-762. [PMID: 38040202 PMCID: PMC11129779 DOI: 10.1016/j.jvs.2023.11.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 11/09/2023] [Accepted: 11/25/2023] [Indexed: 12/03/2023]
Abstract
OBJECTIVE Limited data exist for optimal blood pressure (BP) management during transfer of patients with ruptured abdominal aortic aneurysm (rAAA). This study evaluates the effects of hypertension and severe hypotension during interhospital transfers in a cohort of patients with rAAA in hemorrhagic shock. METHODS We performed a retrospective, single-institution review of patients with rAAA transferred via air ambulance to a quaternary referral center for repair (2003-2019). Vitals were recorded every 5 minutes in transit. Hypertension was defined as a systolic BP of ≥140 mm Hg. The primary cohort included patients with rAAA with hemorrhagic shock (≥1 episode of a systolic BP of <90 mm Hg) during transfer. The primary analysis compared those who experienced any hypertensive episode to those who did not. A secondary analysis evaluated those with either hypertension or severe hypotension <70 mm Hg. The primary outcome was 30-day mortality. RESULTS Detailed BP data were available for 271 patients, of which 125 (46.1%) had evidence of hemorrhagic shock. The mean age was 74.2 ± 9.1 years, 93 (74.4%) were male, and the median total transport time from helicopter dispatch to arrival at the treatment facility was 65 minutes (interquartile range, 46-79 minutes). Among the cohort with shock, 26.4% (n = 33) had at least one episode of hypertension. There were no significant differences in age, sex, comorbidities, AAA repair type, AAA anatomic location, fluid resuscitation volume, blood transfusion volume, or vasopressor administration between the hypertensive and nonhypertensive groups. Patients with hypertension more frequently received prehospital antihypertensives (15% vs 2%; P = .01) and pain medication (64% vs 24%; P < .001), and had longer transit times (36.3 minutes vs 26.0 minutes; P = .006). Episodes of hypertension were associated with significantly increased 30-day mortality on multivariable logistic regression (adjusted odds ratio [aOR], 4.71; 95% confidence interval [CI], 1.54-14.39; P = .007; 59.4% [n = 19] vs 40.2% [n = 37]; P = .01). Severe hypotension (46%; n = 57) was also associated with higher 30-day mortality (aOR, 2.82; 95% CI, 1.27-6.28; P = .01; 60% [n = 34] vs 32% [n = 22]; P = .01). Those with either hypertension or severe hypotension (54%; n = 66) also had an increased odds of mortality (aOR, 2.95; 95% CI, 1.08-8.11; P = .04; 58% [n = 38] vs 31% [n = 18]; P < .01). Level of hypertension, BP fluctuation, and timing of hypertension were not significantly associated with mortality. CONCLUSIONS Hypertensive and severely hypotensive episodes during interhospital transfer were independently associated with increased 30-day mortality in patients with rAAA with shock. Hypertension should be avoided in these patients, but permissive hypotension approaches should also maintain systolic BPs above 70 mm Hg whenever possible.
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Affiliation(s)
- Shimena R Li
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | | | - Katherine M Reitz
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA; Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA; Department of Surgery, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA
| | - Nancy Mikati
- Department of Emergency Medicine, University of Iowa Health Care, Iowa City, IA
| | - Joshua B Brown
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA; Division of Trauma and General Surgery, Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, PA
| | - Edith Tzeng
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA; Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA; Department of Surgery, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA
| | - Michel S Makaroun
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA; Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Francis X Guyette
- Department of Emergency Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Nathan L Liang
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA; Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA.
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Grandi A, Bertoglio L, Lepidi S, Kölbel T, Mani K, Budtz-Lilly J, DeMartino R, Scali S, Hanna L, Troisi N, Calvagna C, D’Oria M. Risk Prediction Models for Peri-Operative Mortality in Patients Undergoing Major Vascular Surgery with Particular Focus on Ruptured Abdominal Aortic Aneurysms: A Scoping Review. J Clin Med 2023; 12:5505. [PMID: 37685573 PMCID: PMC10488165 DOI: 10.3390/jcm12175505] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 08/21/2023] [Accepted: 08/22/2023] [Indexed: 09/10/2023] Open
Abstract
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.
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Affiliation(s)
- Alessandro Grandi
- Department of Vascular Medicine, University Heart and Vascular Center, 20251 Hamburg, Germany
| | - Luca Bertoglio
- Division of Vascular Surgery, Department of Clinical and Experimental Sciences, ASST Spedali Civili of Brescia, 25123 Brescia, Italy
| | - Sandro Lepidi
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste ASUGI, 34129 Trieste, Italy
| | - Tilo Kölbel
- Department of Vascular Medicine, University Heart and Vascular Center, 20251 Hamburg, Germany
| | - Kevin Mani
- Section of Vascular Surgery, Department of Surgical Sciences, University of Uppsala, 751 05 Uppsala, Sweden
| | - Jacob Budtz-Lilly
- Division of Vascular Surgery, Department of Cardiovascular Surgery, Aarhus University Hospital, 8200 Aarhus, Denmark
| | - Randall DeMartino
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN 55905, USA
| | - Salvatore Scali
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL 32610, USA
| | - Lydia Hanna
- Department of Surgery and Cancer, Imperial College London, London SW7 5NH, UK
| | - Nicola Troisi
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy
| | - Cristiano Calvagna
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste ASUGI, 34129 Trieste, Italy
| | - Mario D’Oria
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste ASUGI, 34129 Trieste, Italy
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Özen A, Yılmaz M, Yiğit G, Civelek İ, Türkçü MA, Çetinkaya F, Ünal EU, İşcan HZ. Glasgow Aneurysm Score: a predictor of long-term mortality following endovascular repair of abdominal aortic aneurysm? BMC Cardiovasc Disord 2021; 21:551. [PMID: 34798809 PMCID: PMC8603579 DOI: 10.1186/s12872-021-02366-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 10/28/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To evaluate the value of Glasgow Aneurysm Score (GAS) in predicting long-term mortality and survival in patients who have undergone endovascular aortic aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA). METHODS A retrospective single-center study of 257 patients with non-ruptured AAA undergoing EVAR between January 2013 and 2021. GAS scores were compared between the survivors (group 1) and the long-term mortality (group 2) groups. Cox regression analysis was used to determine independent predictors of late mortality. Receiver operating characteristic curve (ROC) analysis was used to determine the optimum cut-off values of GAS values to determine the effect on late-mortality. Survival analysis was conducted using Kaplan-Meier. RESULTS The study included 257 patients with a mean age of 69.75 ± 7.75 (46-92), who underwent EVAR due to AAA. Average follow up period was 18.98 ± 22.84 months (0-88). Fourty-five (17.8%) mortalities occured during long-term follow-up. A past medical history of cancer resulted in a 2.5 fold increase in risk of long-term mortality (OR: 2.52, 95% CI 1.10-5.76; p = 0.029). GAS values were higher in group 2 compared to group 1 (81.02 ± 10.33 vs. 73.73 ± 10.46; p < 0.001). The area under the ROC curve for GAS was 0.682 and the GAS cut-off value was 77.5 (specificity 64%, p < 0.001). The mortality rates in patients with GAS < 77.5 and GAS > 77.5 were: 12.8% and 24.8% respectively (p = 0.014). Every 10 point increase in GAS resulted in approximately a 2 fold increase in risk of long-term mortality (OR: 1.8, 95% CI 1.3-2.5; p < 0.001). Five year survival rates in patients with GAS < 77.5 and > 77.5 were 75.7% and 61.7%, respectively (p = 0.013). CONCLUSIONS The findings of our study suggests that an increase in GAS score may predict long-term mortality. In addition, the mortality rates in patients above the GAS cut-off value almost doubled compared to those below. Furthermore, the presence of a past history of cancer resulted in a 2.5 fold increase in long-term mortality risk. Addition of cancer to the GAS scoring system may be considered in future studies. Further studies are necessary to consolidate these findings.
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Affiliation(s)
- Anıl Özen
- Department of Cardiovascular Surgery, Ankara City Hospital, Ankara, Turkey.
| | - Metin Yılmaz
- Department of Cardiovascular Surgery, VM Medicalpark Hospital, Ankara, Turkey
| | - Görkem Yiğit
- Department of Cardiovascular Surgery, Yozgat City Hospital, Yozgat, Turkey
| | - İsa Civelek
- Department of Cardiovascular Surgery, Ankara City Hospital, Ankara, Turkey
| | - Mehmet Ali Türkçü
- Department of Cardiovascular Surgery, Ankara City Hospital, Ankara, Turkey
| | - Ferit Çetinkaya
- Department of Cardiovascular Surgery, Ankara City Hospital, Ankara, Turkey
| | - Ertekin Utku Ünal
- Department of Cardiovascular Surgery, Hitit University Faculty of Medicine, Çorum, Turkey
| | - Hakkı Zafer İşcan
- Department of Cardiovascular Surgery, Ankara City Hospital, Ankara, Turkey
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Bellamkonda KS, Yousef S, Zhang Y, Dardik A, Geirsson A, Chaar CIO. Endograft type and anesthesia mode are associated with mortality of endovascular aneurysm repair for ruptured abdominal aortic aneurysms. Vascular 2020; 29:155-162. [PMID: 32787557 DOI: 10.1177/1708538120947859] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Endovascular aneurysm repair has become the primary treatment modality for ruptured infrarenal abdominal aortic aneurysm. This study examines the impact of endograft type on perioperative outcomes for ruptured infrarenal abdominal aortic aneurysm. METHOD The targeted endovascular aneurysm repair files of the American College of Surgeons National Surgical Quality Improvement Program database (2012-2017) were used. Only patients treated for ruptured infrarenal abdominal aortic aneurysm were included. All patients requiring concomitant stenting of the visceral arteries or aneurysmal iliac arteries or open abdominal surgery were excluded. The characteristics of patients treated with the different endografts and the corresponding outcomes were compared using Stata software. RESULTS There were 479 patients treated with the three most common endografts: Cook Zenith (n = 127), Gore Excluder (n = 239), and Medtronic Endurant (n = 113). The number of other endografts was too small for statistical analysis. Compared to patients treated with Excluder or Endurant, the patients treated with Zenith had significantly lower body mass index (P < .001) and were less likely to be white (P < .001). On the other hand, patients treated with Endurant were less likely to be smoker (P = .016). Patients treated with Zenith had significantly larger ruptured infrarenal abdominal aortic aneurysm diameter (P = .045). The overall mortality was 18% and morbidity 74.3%. There was a statistically significant difference in overall mortality (Zenith = 11.8%, Excluder = 18%, Endurant = 24.8%, P = .033) but not morbidity (P = .808) between the three groups. Post hoc analysis for overall mortality showed only significant difference between Zenith and Endurant. The difference in mortality was not significant in patients presenting with ruptured infrarenal abdominal aortic aneurysm without hypotension (P = .065). On multivariable analysis, treatment with the Endurant endograft was associated with increased mortality compared to Zenith (odds ratio = 3.0 [confidence interval 1.31-6.7]). General anesthesia (odds ratio = 2.67 [confidence interval 1.02-7.02]), rupture with hypotension (odds ratio = 4.49 [confidence interval 2.54-7.95]), and dependent functional status (odds ratio = 5.7 [confidence interval 1.96-16.59]) were independently associated with increased mortality while increasing body mass index (odds ratio = 0.97 [confidence interval 0.95-0.99]) was associated with reduced risk of mortality. CONCLUSIONS This study highlights contemporary outcomes of endovascular aneurysm repair for ruptured infrarenal abdominal aortic aneurysm with relatively low mortality. Endograft type and anesthesia technique are modifiable factors that can potentially improve outcomes. Significant variation in the outcomes of the different endografts warrants further research.
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Affiliation(s)
| | - Sameh Yousef
- Section of Cardiac Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Yawei Zhang
- Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Alan Dardik
- Section of Vascular Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Arnar Geirsson
- Section of Cardiac Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Cassius I Ochoa Chaar
- Section of Vascular Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
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5
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Smidfelt K, Nordanstig J, Davidsson A, Törngren K, Langenskiöld M. Misdiagnosis of ruptured abdominal aortic aneurysms is common and is associated with increased mortality. J Vasc Surg 2020; 73:476-483.e3. [PMID: 32623108 DOI: 10.1016/j.jvs.2020.06.047] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 06/02/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To investigate the rate of misdiagnosis in the emergency department in patients with ruptured abdominal aortic aneurysms (rAAAs), and to investigate how misdiagnosis affects rAAA mortality. METHODS Data were extracted from the Swedish Cause of Death Registry and the Swedish National Registry for Vascular Surgery from 2010 to 2015. All rAAA patients registered in the health care system in the west of Sweden were identified. Medical charts for rAAA patients were reviewed, and patients who were correctly diagnosed at the first assessment in the emergency department were compared with patients who were misdiagnosed. RESULTS Altogether, 455 patients with rAAA were identified, including both patients who underwent surgery and those who did not. One hundred seventy-seven (38.9%) were initially misdiagnosed. The mortality rate was 74.6% in patients who were misdiagnosed, as compared with 62.9% in correctly diagnosed patients (P = .01). The adjusted odds ratio for mortality in misdiagnosed patients relative to correctly diagnosed patients was 1.83 (95% confidence interval, 1.13-2.96) (P = .01). When excluding patients offered palliative care (n = 134) after detection of the rAAA, the mortality in initially misdiagnosed patients was 65.1% as compared with 46.4% in correctly diagnosed patients (P = .001). In patients reaching surgical intervention, 37 (45.1%) of the primarily misdiagnosed patients died (30-day or in-hospital mortality) as compared with 63 (38.0%) of the correctly diagnosed (P = .34). CONCLUSIONS Misdiagnosis is common in patients with rAAA, and it is associated with a substantially higher risk of dying from the ruptured aneurysm.
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Affiliation(s)
- Kristian Smidfelt
- Department of Vascular Surgery and Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska University Hospital, The Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden.
| | - Joakim Nordanstig
- Department of Vascular Surgery and Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska University Hospital, The Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | | | - Kristina Törngren
- Department of Molecular and Clinical Medicine, Sahlgrenska University Hospital and the Institute of Medicine, The Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Marcus Langenskiöld
- Department of Vascular Surgery and Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska University Hospital, The Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
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6
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Yanquez FJ, Peterson A, Weinkauf C, Goshima KR, Zhou W, Mohler J, Ehsani H, Toosizadeh N. Sensor-Based Upper-Extremity Frailty Assessment for the Vascular Surgery Risk Stratification. J Surg Res 2020; 246:403-410. [DOI: 10.1016/j.jss.2019.09.029] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 08/14/2019] [Accepted: 09/13/2019] [Indexed: 02/06/2023]
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Hollingsworth AC, Dawkins C, Wong PF, Walker P, Milburn S, Mofidi R. Aneurysm Morphology Is a More Significant Predictor of Survival than Hardman's Index in Patients with Ruptured or Acutely Symptomatic Abdominal Aortic Aneurysms. Ann Vasc Surg 2019; 58:222-231. [DOI: 10.1016/j.avsg.2018.10.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 10/01/2018] [Accepted: 10/08/2018] [Indexed: 02/09/2023]
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Rylski B, Pacini D, Beyersdorf F, Quintana E, Schachner T, Tsagakis K, Ronchey S, Durko A, De Paulis R, Siepe M, Roselli EE, Carrel T, Czerny M, Schoenhoff FS, Rylski B, Pacini D, Quintana E, Schachner T, Tsagakis K, Ronchey S, Durko A, Roselli EE, Schoenhoff FS, Beyersdorf F, Czerny M, De Paulis R, Siepe M. Standards of reporting in open and endovascular aortic surgery (STORAGE guidelines). Eur J Cardiothorac Surg 2019; 56:10-20. [DOI: 10.1093/ejcts/ezz145] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 04/11/2019] [Accepted: 04/16/2019] [Indexed: 12/24/2022] Open
Affiliation(s)
- Bartosz Rylski
- Department of Cardiovascular Surgery, Faculty of Medicine, Heart Centre Freiburg University, University of Freiburg, Freiburg, Germany
| | - Davide Pacini
- Cardiac Surgery Unit, Cardio-Thoraco-Vascular Department, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, Faculty of Medicine, Heart Centre Freiburg University, University of Freiburg, Freiburg, Germany
| | - Eduard Quintana
- Cardiovascular Surgery Department, Institut Clínic Cardiovascular, Hospital Clínic de Barcelona, University of Barcelona Medical School, Barcelona, Spain
| | - Thomas Schachner
- Innsbruck Medical University, University Clinic for Cardiac Surgery, Innsbruck, Austria
| | - Konstantinos Tsagakis
- Department of Thoracic and Cardiovascular Surgery, West-German Heart and Vascular Center Essen, University Duisburg-Essen, Essen, Germany
| | - Sonia Ronchey
- Department of Vascular Surgery, San Filippo Neri Hospital, Rome, Italy
| | - Andras Durko
- Department of Cardio-Thoracic Surgery, Erasmus Medical Center, Rotterdam, Netherlands
| | | | - Matthias Siepe
- Department of Cardiovascular Surgery, Faculty of Medicine, Heart Centre Freiburg University, University of Freiburg, Freiburg, Germany
| | - Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Thierry Carrel
- Department of Cardiovascular Surgery, University Hospital Bern, Bern, Switzerland
| | - Martin Czerny
- Department of Cardiovascular Surgery, Faculty of Medicine, Heart Centre Freiburg University, University of Freiburg, Freiburg, Germany
| | - Florian S Schoenhoff
- Department of Cardiovascular Surgery, University Hospital Bern, Bern, Switzerland
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9
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Fujimura N, Takahara M, Isogai N, Yashiro H, Shibutani S, Inoue M, Obara H, Ogino H. Retroperitoneal hematoma volume is a good predictor of perioperative mortality after endovascular aneurysm repair for ruptured abdominal aortic aneurysm. J Vasc Surg 2018; 68:998-1006.e2. [DOI: 10.1016/j.jvs.2018.01.048] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2017] [Accepted: 01/22/2018] [Indexed: 11/28/2022]
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10
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Gupta AK, Dakour-Aridi H, Locham S, Nejim B, Veith FJ, Malas MB. Real-world evidence of superiority of endovascular repair in treating ruptured abdominal aortic aneurysm. J Vasc Surg 2018; 68:74-81. [DOI: 10.1016/j.jvs.2017.11.065] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 11/05/2017] [Indexed: 11/26/2022]
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11
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Amato B, Fugetto F, Compagna R, Zurlo V, Barbetta A, Petrella G, Aprea G, Danzi M, Rocca A, de Franciscis S, Serra R. Endovascular repair versus open repair in the treatment of ruptured aortic aneurysms: a systematic review. MINERVA CHIR 2018; 74:472-480. [PMID: 29806754 DOI: 10.23736/s0026-4733.18.07768-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Rupture of abdominal aortic aneurysm remains a fatal event in up to 65% of cases and emergency open surgery (ruptured open aneurysm repair or rOAR) has a great intraoperative mortality of about 30-50%. The introduction of endovascular repair of abdominal aortic aneurysm (ruptured endovascular aneurysm repair or rEVAR) has rapidly challenged the conventional approach to this catastrophic event. The purpose of this systematic review is to compare the outcomes of open surgical repair and endovascular interventions. EVIDENCE ACQUISITION A literature search was performed using Medline, Scopus, and Science Direct from August 2010 to March 2017 using keywords identified and agreed by the authors. Randomized trials, cohort studies, and case-report series were contemplated to give a breadth of clinical data. EVIDENCE SYNTHESIS Ninety-three studies were included in the final analysis. Thirty-five (50.7%) of the listed studies evaluating the within 30 days mortality rates deposed in favor of rEVAR, while the others (comprising all four included RCTs) failed detecting any difference. Late mortality rates were found to be lower in rEVAR group in seven on twenty-seven studies (25.9%), while one (3.7%) reported higher mortality rates following rEVAR performed before 2005, one found lower incidence of mortality at 6 months in the endovascular group but higher rates in the same population at 8 years of follow-up, and the remaining (66.7%) (including all three RCTs) failed finding any benefit of rEVAR on rOAR. A lower incidence of complications was reported by thirteen groups (46.4%), while other thirteen studies did not find any difference between rEVAR and rOAR. Each of these two conclusions was corroborated by one RCTs. Other two studies (7.2%) found higher rates of tracheostomies, myocardial infarction, and acute tubular necrosis or respiratory, urinary complications, and acute renal failure respectively in rOAR group. The majority of studies (59.0%, 72.7%, and 89.3%, respectively) and all RCTs found significantly lower rates of length of hospitalization, intensive care unit transfer, and blood loss with or without transfusion need in rEVAR group. The large majority of the studies did not specified neither the type nor the brands of employed stent grafts. CONCLUSIONS The bulk of evidence regarding the comparison between endovascular and open surgery approach to RAAA points to: 1) non-inferiority of rEVAR in terms of early (within 30 days) and late mortality as well as rate of complications and length of hospitalization, with trends of better outcomes associated to the endovascular approach; 2) significantly better outcomes in terms of intensive care unit transfer and blood loss with or without transfusion need in the rEVAR group. These conclusions reflect the results of the available RCTs included in the present review. Thus rEVAR can be considered a safe method in treating RAAA and we suggest that it should be preferred when technically feasible. However, more RCTs are needed in order to give strength of these evidences, bring to definite clinical recommendations regarding this subject, and assess the superiority (if present) of one or more brands of stent grafts over the others.
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Affiliation(s)
- Bruno Amato
- Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology, Magna Graecia University, Catanzaro, Italy.,Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Francesco Fugetto
- Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology, Magna Graecia University, Catanzaro, Italy
| | - Rita Compagna
- Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology, Magna Graecia University, Catanzaro, Italy.,Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Valeria Zurlo
- Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology, Magna Graecia University, Catanzaro, Italy
| | - Andrea Barbetta
- Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology, Magna Graecia University, Catanzaro, Italy.,Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy
| | | | - Giovanni Aprea
- Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology, Magna Graecia University, Catanzaro, Italy.,Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Michele Danzi
- Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology, Magna Graecia University, Catanzaro, Italy.,Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Aldo Rocca
- Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology, Magna Graecia University, Catanzaro, Italy.,Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Stefano de Franciscis
- Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology, Magna Graecia University, Catanzaro, Italy.,Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy
| | - Raffaele Serra
- Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology, Magna Graecia University, Catanzaro, Italy - .,Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy
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12
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Vetrhus M, Reite A, Vennesland JB, Søreide K. Characteristics, Stratification and Time to Death in a Population-Based Cohort of Patients with Ruptured Abdominal Aortic Aneurysms Not Undergoing Surgery. World J Surg 2017; 42:2269-2276. [PMID: 29288315 DOI: 10.1007/s00268-017-4445-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND The available literature on ruptured abdominal aortic aneurysms (rAAA) centers on survival after operation and commonly, reasons why some patients do not undergo surgery are not addressed. The aim of the present study is to examine, in a population-based cohort, the characteristics, stratification and time to death of patients admitted to hospital, but not undergoing operation for rAAA. METHODS A retrospective, single-center study. All patients admitted to Stavanger University Hospital from the primary catchment area with rAAA on admission or in-hospital from 2000 to 2014 were included. RESULTS Altogether 214 patients with rAAA were identified; 57 (27%) patients did not undergo surgery. The proportion of women was significantly higher (37 vs. 14%; p < .001) in patients not having surgery. The reasons for not undergoing operation were patient 'not fit for surgery' (30%), 'dying or agonal' at time of diagnosis (26%), 'did not want operation' (21%) and 'diagnosed at autopsy' (23%). Of the non-operated patients, 45 had rAAA on arrival to hospital, 12 had in-hospital rupture and 21 patients had previously been diagnosed with an abdominal aortic aneurysm. Non-operative treatment was uniformly fatal. The 45 patients with rAAA on arrival were scored using four scoring systems, the predicted mortality varied widely, and the median time from admission to death was 7.4 h (range 0-1337). CONCLUSION In about half of patients, a decision not to operate was made by the consultant vascular surgeon or the patient. In the subgroup of patients not diagnosed until autopsy or having an in-hospital rupture, an earlier diagnosis might have altered the outcome.
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Affiliation(s)
- Morten Vetrhus
- Department of Surgery, Vascular Surgery Unit, Stavanger University Hospital, PO Box 8100, 4068, Stavanger, Norway.
| | - Andreas Reite
- Department of Surgery, Vascular Surgery Unit, Stavanger University Hospital, PO Box 8100, 4068, Stavanger, Norway
| | - Jørgen B Vennesland
- Department of Surgery, Vascular Surgery Unit, Stavanger University Hospital, PO Box 8100, 4068, Stavanger, Norway
| | - Kjetil Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
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13
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Lijftogt N, Luijnenburg TWF, Vahl AC, Wilschut ED, Leijdekkers VJ, Fiocco MF, Wouters MWJM, Hamming JF. Systematic review of mortality risk prediction models in the era of endovascular abdominal aortic aneurysm surgery. Br J Surg 2017; 104:964-976. [PMID: 28608956 DOI: 10.1002/bjs.10571] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 02/16/2017] [Accepted: 03/23/2017] [Indexed: 11/09/2022]
Abstract
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.
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Affiliation(s)
- N Lijftogt
- Departments of Vascular Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - T W F Luijnenburg
- Departments of Medicine, Leiden University Medical Centre, Leiden, The Netherlands
| | - A C Vahl
- Department of Surgery Onze Lieve Vrouwe Gasthuis, Dutch Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - E D Wilschut
- Departments of Vascular Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - V J Leijdekkers
- Department of Surgery Onze Lieve Vrouwe Gasthuis, Dutch Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - M F Fiocco
- Department of Medical Statistics and Bioinformatics, Leiden University, Leiden, The Netherlands.,Institute of Mathematics, Leiden University, Leiden, The Netherlands
| | - M W J M Wouters
- Scientific Bureau, Dutch Institute for Clinical Auditing, Leiden, The Netherlands.,Department of Surgery, Dutch Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - J F Hamming
- Departments of Vascular Surgery, Leiden University Medical Centre, Leiden, The Netherlands
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14
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von Meijenfeldt GCI, van Beek SC, Bastos Gonçalves F, Verhagen HJM, Zeebregts CJ, Vahl AC, Wisselink W, van der Laan MJ, Balm R. Development and External Validation of a Model Predicting Death After Surgery in Patients With a Ruptured Abdominal Aortic Aneurysm: The Dutch Aneurysm Score. Eur J Vasc Endovasc Surg 2016; 53:168-174. [PMID: 27916478 DOI: 10.1016/j.ejvs.2016.10.024] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Accepted: 10/25/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVE The decision whether or not to proceed with surgical intervention of a patient with a ruptured abdominal aortic aneurysm (rAAA) is very difficult in daily practice. The primary objective of the present study was to develop and to externally validate a new prediction model: the Dutch Aneurysm Score (DAS). METHODS With a prospective cohort of 10 hospitals (n = 508) the DAS was developed using a multivariate logistic regression model. Two retrospective cohorts with rAAA patients from two hospitals (n = 373) were used for external validation. The primary outcome was the combined 30 day and in-hospital death rate. Discrimination (AUC), calibration plots, and the ability to identify high risk patients were compared with the more commonly used Glasgow Aneurysm Score (GAS). RESULTS After multivariate logistic regression, four pre-operative variables were identified: age, lowest in hospital systolic blood pressure, cardiopulmonary resuscitation, and haemoglobin level. The area under the receiver operating curve (AUC) for the DAS was 0.77 (95% CI 0.72-0.82) compared with the GAS with an AUC of 0.72 (95% CI 0.67-0.77). The DAS showed a death rate in patients with a predicted death rate ≥80% of 83%. CONCLUSIONS The present study shows that the DAS has a higher discriminative performance (AUC) compared with the GAS. All clinical variables used for the DAS are easy to obtain. Identification of low risk patients with the DAS can potentially reduce turndown rates. The DAS can reliably be used by clinicians to make a more informed decision in dialogue with the patient and their family whether or not to proceed with surgical intervention.
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Affiliation(s)
- G C I von Meijenfeldt
- Department of Surgery (Division of Vascular Surgery), University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - S C van Beek
- Department of Surgery (Division of Vascular Surgery), Academic Medical Center, Amsterdam, The Netherlands
| | - F Bastos Gonçalves
- Department of Angiology and Vascular Surgery, Hospital de Santa Marta, CHLC, Lisbon, Portugal; Department of Surgery (Division of Vascular Surgery), Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - H J M Verhagen
- Department of Surgery (Division of Vascular Surgery), Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - C J Zeebregts
- Department of Surgery (Division of Vascular Surgery), University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - A C Vahl
- Department of Surgery (Division of Vascular Surgery), Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - W Wisselink
- Department of Surgery (Division of Vascular Surgery), VU University Medical Center, Amsterdam, The Netherlands
| | - M J van der Laan
- Department of Surgery (Division of Vascular Surgery), University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
| | - R Balm
- Department of Surgery (Division of Vascular Surgery), Academic Medical Center, Amsterdam, The Netherlands
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15
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Reite A, Søreide K, Vetrhus M. Comparing the accuracy of four prognostic scoring systems in patients operated on for ruptured abdominal aortic aneurysms. J Vasc Surg 2016; 65:609-615. [PMID: 27743804 DOI: 10.1016/j.jvs.2016.08.082] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Accepted: 08/18/2016] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Ruptured abdominal aortic aneurysms (rAAAs) are associated with high mortality and morbidity. Several prognostic scoring systems are available for prediction of outcome, but scarcity of external validation and evaluation of predictive value has hampered widespread implementation. The aim of this study was to examine the discriminatory value of four scores in a consecutive Norwegian cohort. METHODS This was a retrospective study of a consecutive series of patients operated on for primary rAAA at Stavanger University Hospital from January 2000 to December 2014. The Hardman Index, Vancouver Score (VS), updated Glasgow Aneurysm Score, and Edinburgh Ruptured Aneurysm Score (ERAS) were calculated. Predictive ability in discriminating survivors and nonsurvivors was compared using receiver operating characteristics analyses and presented as area under the curve. RESULTS Altogether, 177 patients underwent surgery for rAAA. Mortality at 30 days was 46.3%. In receiver operating characteristics analysis, the Hardman Index had an area under the curve of 0.674 (95% confidence interval [CI], 0.588-0.753); the VS, 0.684 (95% CI, 0.610-0.752); the Glasgow Aneurysm Score, 0.680 (95% CI, 0.605-0.749); and the ERAS, 0.586 (95% CI, 0.509-0.660). VS had a significantly better fit than ERAS (P = .022). CONCLUSIONS The accuracy of the available scores is limited. The findings question the clinical value of such scores for decision-making.
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Affiliation(s)
- Andreas Reite
- Department of Surgery, Vascular Surgery Unit, Stavanger University Hospital, Stavanger, Norway
| | - Kjetil Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Morten Vetrhus
- Department of Surgery, Vascular Surgery Unit, Stavanger University Hospital, Stavanger, Norway.
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16
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Novo Martínez GM, Ballesteros Pomar M, Menéndez Sánchez E, Santos Alcántara E, Rodríguez Fernández I, Zorita Calvo AM. Endovascular repair versus open surgery in patients in the treatment of the ruptured of aneurysms abdominal. Cir Esp 2016; 95:38-43. [PMID: 27702437 DOI: 10.1016/j.ciresp.2016.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Revised: 07/28/2016] [Accepted: 07/29/2016] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Rupture of abdominal aortic aneurysm is still a difficult challenge for the vascular surgeon due to the high perioperative mortality. The aim of our study is to describe the characteristics of the population as well as to compare morbidity and mortality in patients undergoing open surgery or endovascular repair in our center. METHODS Database with 82 rAAA between January 2002-December 2014, studying two cohorts, open surgery and endovascular repair. Epidemiologic, clinical, surgical techniques, perioperative mortality and complications are analyzed. RESULTS 82 rAAA cases were operated (men: 80, women: 2). Mean age 72±9.6 years. 76.8% (63 cases) was performed by open surgery. BACKGROUND smokers 59, 7%, alcoholism 19.5%, DM 10.9%, AHT: 53.6%, dyslipidemia 30.5%. The most frequent clinical presentation was abdominal pain with lumbar irradiation: 50 cases (20.7% associating syncope). Overall hospital mortality was 58.5%. Hemodynamic shock prior to intervention was associated with increased mortality (p <.001). Anemia, leukocytosis, aneurysm size, sex and age did not show a statistically significant difference with respect to mortality (p>.05). The presence of iliac aneurysms was associated with increased mortality (p <.0045). Perioperative mortality in endovascular repair was 42%, and in open surgery was 63.5% (p>.05). Hospital stay was lower in the endovascular group (p=.3859). CONCLUSIONS Hemodynamic shock and the presence of concomitant iliac aneurysms have a statistically significant association with perioperative mortality in both groups. We found clinically significant differences in mortality, complications and hospital stay when comparing both groups with better results for EVAR, without statistically significant differences.
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17
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The Rationale for Continuing Open Repair of Ruptured Abdominal Aortic Aneurysm. Ann Vasc Surg 2016; 36:64-73. [DOI: 10.1016/j.avsg.2016.02.037] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Revised: 02/07/2016] [Accepted: 02/25/2016] [Indexed: 02/05/2023]
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Patelis N, Moris D, Karaolanis G, Georgopoulos S. Endovascular vs. Open Repair for Ruptured Abdominal Aortic Aneurysm. Med Sci Monit Basic Res 2016; 22:34-44. [PMID: 27090791 PMCID: PMC4847558 DOI: 10.12659/msmbr.897601] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Background Patients presenting with ruptured abdominal aortic aneurysms are most often treated with open repair despite the fact that endovascular aneurysm repair is a less invasive and widely accepted method with clear benefits for elective aortic aneurysm patients. A debate exists regarding the definitive benefit in endovascular repair for patients with a ruptured abdominal aortic aneurysm. The aim of this literature review was to determine if any trends exist in favor of either open or endovascular repair. Material/Methods A literature search was performed using PUBMED, OVID, and Google Scholar databases. The search yielded 64 publications. Results Out of 64 publications, 25 were retrospective studies, 12 were population-based, 21 were prospective, 5 were the results of RCTs, and 1 was a case-series. Sixty-one studies reported on early mortality and provided data comparing endovascular repair (rEVAR) and open repair (rOR) for ruptured abdominal aneurysm groups. Twenty-nine of these studies reported that rEVAR has a lower early mortality rate. Late mortality after rEVAR compared to that of rOR was reported in 21 studies for a period of 3 to 60 months. Results of 61.9% of the studies found no difference in late mortality rates between these 2 groups. Thirty-nine publications reported on the incidence of complications. Approximately half of these publications support that the rEVAR group has a lower complication rate and the other half found no difference between the groups. Length of hospital stay has been reported to be shorter for rEVAR in most studies. Blood loss and need for transfusion of either red cells or fresh frozen plasma was consistently lower in the rEVAR group. Conclusions Differences between the included publications affect the outcomes. Randomized control trials have not been able to provide clear conclusions. rEVAR can now be considered a safe method of treating rAAA, and is at least equal to the well-established rOR method.
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Affiliation(s)
- Nikolaos Patelis
- Vascular Unit, First Department of Surgery, Laiko General Hospital, Medical School, National & Kapodistrian University of Athens, Athens, Greece
| | - Demetrios Moris
- Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Georgios Karaolanis
- Vascular Unit, First Department of Surgery, Laiko General Hospital, Medical School, National & Kapodistrian University of Athens, Athens, Greece
| | - Sotiris Georgopoulos
- Vascular Unit, First Department of Surgery, Laiko General Hospital, Medical School, National & Kapodistrian University of Athens, Athens, Greece
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Li Y, Li Z, Wang S, Chang G, Wu R, Hu Z, Yin H, Wang J, Yao C. Endovascular versus Open Surgery Repair of Ruptured Abdominal Aortic Aneurysms in Hemodynamically Unstable Patients: Literature Review and Meta-Analysis. Ann Vasc Surg 2016; 32:135-44. [DOI: 10.1016/j.avsg.2015.09.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Revised: 09/18/2015] [Accepted: 09/25/2015] [Indexed: 12/16/2022]
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20
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Lahoz C, Gracia CE, García LR, Montoya SB, Hernando ÁB, Heredero ÁF, Tembra MS, Velasco MB, Guijarro C, Ruiz EB, Pintó X, de Ceniga MV, Moñux Ducajú G. [Not Available]. CLINICA E INVESTIGACION EN ARTERIOSCLEROSIS : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE ARTERIOSCLEROSIS 2016; 28 Suppl 1:1-49. [PMID: 27107212 DOI: 10.1016/s0214-9168(16)30026-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Affiliation(s)
- Carlos Lahoz
- Unidad de Lípidos y Riesgo Vascular, Servicio de Medicina Interna, Hospital Carlos III, Madrid, España.
| | - Carlos Esteban Gracia
- Servicio de Angiología y Cirugía Vascular, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, España
| | | | - Sergi Bellmunt Montoya
- Servicio de Angiología y Cirugía Vascular, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - Ángel Brea Hernando
- Unidad de Lípidos, Servicio de Medicina Interna, Hospital San Pedro, Logroño, España
| | | | - Manuel Suárez Tembra
- Unidad de Lípidos y Riesgo Cardiovascular, Servicio de Medicina Interna, Hospital San Rafael, A Coruña, España
| | - Marta Botas Velasco
- Servicio de Angiología y Cirugía Vascular, Hospital de Cabueñes, Gijón, España
| | - Carlos Guijarro
- Consulta de Riesgo Vascular, Unidad de Medicina Interna, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, España
| | - Esther Bravo Ruiz
- Servicio de Angiología y Cirugía Vascular, Hospital Universitario de Basurto, Bilbao, España
| | - Xavier Pintó
- Unidad de Riesgo Vascular, Servicio de Medicina Interna, Hospital Universitario de Bellvitge, L' Hospitalet de Llobregat, Barcelona, España
| | - Melina Vega de Ceniga
- Servicio de Angiología y Cirugía Vascular, Hospital de Galdakao-Usansolo, Vizcaya, España
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Majd P, Mylonas S, Gawenda M, Brunkwall J. External Validation of Risk Stratification Models Predicting the Immediate Mortality After Open Repair of Ruptured AAA. World J Surg 2016; 40:1771-7. [PMID: 26913734 DOI: 10.1007/s00268-016-3461-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Preoperative risk stratification of the immediate postoperative death after surgery may be helpful for the decision-making for patients with ruptured AAAs (rAAs). The purpose of this study was to apply and validate the Glasgow aneurysm score (GAS) and the Hardman Index (HI) in predicting 30-day/in-hospital mortality in open surgical repair (OSR) and endovascular repair (rEVAR) of rAAAs. METHODS We conducted a retrospective review of a prospectively created database including all patients with a rAAA referred to our Institution between August 1998 and December 2014. Primary outcome was 30-day/in-hospital mortality. Multivariate logistic regression analysis was used to identify independent risk factors. The receiver-operator characteristic curve was used to determine the value of the HI and GAS in predicting 30-day/in-hospital death. RESULTS A total of 150 patients (130 patients received OSR, 20 patients rEVAR) were included in our analysis. The 30-day/in-hospital mortality was 34.0 % for the entire cohort: 36.15 % for OSR group and 20.0 % for rEVAR group (p 0.210). A multivariate analysis in the OSR group evidenced that unconsciousness was a statistically significant [adjusted odds ratio (OR) 8.00] predictor of 30-day/in-hospital mortality. The mean GAS was 86.9 ± 16.1 for the OSR group and 88.1 ± 11.2 for the rEVAR group (p 0.773). The AUC for GAS was 0.805 among OSR patients and 0.975 among rEVAR patients. The mean HI in the OSR group was 1.11 ± 1.0 and the AUC for HI was 0.82. CONCLUSIONS Surgical repair of rAAAs is still associated with a considerable mortality rate. We confirmed the great discriminative ability of GAS in patients with rAAAs treated with OSR. With regard to HI, this scoring system could accurately predict early mortality after OSR in our cohort but failed to identify patients at highest risk for postoperative mortality.
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Affiliation(s)
- Payman Majd
- Department of Vascular and Endovascular Surgery, University of Cologne, Cologne, Germany.
| | - Spyridon Mylonas
- Department of Vascular and Endovascular Surgery, University of Cologne, Cologne, Germany
| | - Michael Gawenda
- Department of Vascular and Endovascular Surgery, University of Cologne, Cologne, Germany
| | - Jan Brunkwall
- Department of Vascular and Endovascular Surgery, University of Cologne, Cologne, Germany
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Krenzien F, Wiltberger G, Hau HM, Matia I, Benzing C, Atanasov G, Schmelzle M, Fellmer P. Risk Stratification of Ruptured Abdominal Aortic Aneurysms in Patients Treated by Open Surgical Repair. Eur J Vasc Endovasc Surg 2016; 51:30-6. [DOI: 10.1016/j.ejvs.2015.07.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Accepted: 07/01/2015] [Indexed: 11/26/2022]
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Weingarten TN, Thompson LT, Licatino LK, Bailey CH, Schroeder DR, Sprung J. Ruptured Abdominal Aortic Aneurysm: Prediction of Mortality From Clinical Presentation and Glasgow Aneurysm Score. J Cardiothorac Vasc Anesth 2015; 30:323-9. [PMID: 26811271 DOI: 10.1053/j.jvca.2015.10.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To examine association of presenting clinical acuity and Glasgow Aneurysm Score (GAS) with perioperative and 1-year mortality. DESIGN Retrospective chart review. SETTING Major tertiary care facility. PARTICIPANTS Patients with ruptured abdominal aortic aneurysm (rAAA) from 2003 through 2013. INTERVENTIONS Emergency repair of rAAA. MEASUREMENTS AND MAIN RESULTS The authors reviewed outcomes after stable versus unstable presentation and by GAS. Unstable presentation included hypotension, cardiac arrest, loss of consciousness, and preoperative tracheal intubation. In total, 125 patients (40 stable) underwent repair. Perioperative mortality rates were 41% and 12% in unstable and stable patients, respectively (p<0.001). Unstable status had 88% sensitivity and 41% specificity for predicting perioperative mortality. Using logistic regression, higher GAS was associated with perioperative mortality (p<0.001). Using receiver operating characteristic analysis, the area under the curve was 0.72 (95% CI, 0.62-0.82) and cutoff GAS≥96 had 63% and 72% sensitivity and specificity, respectively. Perioperative mortality for GAS≥96 was 51% (25/49), whereas it was 20% (15/76) for GAS≤95. The estimated 1-year survival (95% CI) was 75% (62%-91%) for stable patients and 48% (38%-60%) for unstable patients. Estimated 1-year survival (95% CI) was 23% (13%-40%) for GAS≥96 and 77% (67%-87%) for GAS≤95. CONCLUSIONS Clinical presentation and GAS identified patients with rAAA who were likely to have a poor surgical outcome. GAS≥96 was associated with poor long-term survival, but>20% of these patients survived 1 year. Thus, neither clinical presentation nor GAS provided reliable guidance for decisions regarding futility of surgery.
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Affiliation(s)
| | | | | | | | - Darrell R Schroeder
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
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Improved trends in patient survival and decreased major complications after emergency ruptured abdominal aortic aneurysm repair. J Vasc Surg 2015; 63:39-47. [PMID: 26506941 DOI: 10.1016/j.jvs.2015.08.050] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2015] [Accepted: 08/02/2015] [Indexed: 12/20/2022]
Abstract
BACKGROUND Improved trends in patient survival and decreased major complications after emergency ruptured abdominal aortic aneurysm (AAA) repair. Emergency AAA repair carries a high risk of morbidity and mortality. This study seeks to examine morbidity and mortality trends from the National Surgical Quality Improvement Program (NSQIP) database, and identify potential risk factors. METHODS All emergency AAA repairs were identified using the NSQIP database from 2005 to 2011. Univariate analysis (using the Student t, χ(2), and Fisher's exact tests) and multivariate logistic regression was performed to examine trends in mortality and morbidity. RESULTS Out of 2761 patients who underwent emergency AAA repair, 321 (11.6%) died within 24 hours of surgery. Of the remaining 2440 patients, 1133 (46.4%) experienced major complications and 459 (18.8%) died during the postoperative period. From 2005 to 2011, there was a significant decrease in patient mortality, particularly in patients who survived the perioperative period (P = .002). Total complications increased overall (P < .0001); however, major complications decreased from 58.7% in 2005 to 42.6% in 2011 (P < .0001) among patients who survived beyond 24 hours. The use of endovascular aortic repair (EVAR) increased over the study period (P < .0001). On multivariate analysis of patients who survived past the initial 24-hour period, advancing age (odds ratio [OR], 1.1; 95% confidence interval [CI], 1.0-1.1), chronic obstructive pulmonary disease (OR, 2.6; 95% CI, 1.7-4.1), dependent functional status (OR, 2.0; 95% CI, 1.2-3.2), and presence of a major complication (OR, 3.1; 95% CI, 2.0-5.0) were significantly associated with death, whereas presence of a senior resident (OR, 0.4; 95% CI, 0.3-0.6) or fellow (OR 0.3; 95% CI, 0.2-0.6) was inversely associated with death. EVAR was not associated with death, but was associated with 30-day complications (OR, 0.5; 95% CI, 0.3-0.6). CONCLUSIONS Patient survival has increased from 2005 to 2011 after emergency AAA repair, with a significant improvement particularly in patients who survive past the first 24 hours. EVAR was not associated with mortality, but was protective of 30-day complications. Although the total number of complications increased, the number of major complications decreased over the study period, suggesting that newer techniques and patient care protocols may be improving outcomes.
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Castro‐Ferreira R, Neiva‐Sousa M, Sampaio S, Gonçalves Dias P, da Costa‐Pereira A, Freitas A. Dez anos de tratamento de aneurismas da aorta abdominal – exclusão endovascular vs. cirurgia aberta nas diferentes regiões portuguesas. ANGIOLOGIA E CIRURGIA VASCULAR 2015. [DOI: 10.1016/j.ancv.2014.11.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
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Luebke T, Brunkwall J. Risk-Adjusted Meta-analysis of 30-Day Mortality of Endovascular Versus Open Repair for Ruptured Abdominal Aortic Aneurysms. Ann Vasc Surg 2015; 29:845-63. [DOI: 10.1016/j.avsg.2014.12.014] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Revised: 12/19/2014] [Accepted: 12/22/2014] [Indexed: 12/20/2022]
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Lee CW, Bae M, Chung SW. General considerations of ruptured abdominal aortic aneurysm: ruptured abdominal aortic aneurysm. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2015; 48:1-6. [PMID: 25705591 PMCID: PMC4333847 DOI: 10.5090/kjtcs.2015.48.1.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Revised: 07/07/2014] [Accepted: 07/07/2014] [Indexed: 01/24/2023]
Abstract
Although development of surgical technique and critical care, ruptured abdominal aortic aneurysm still carries a high mortality. In order to obtain good results, various efforts have been attempted. This paper reviews initial management of ruptured abdominal aortic aneurysm and discuss the key point open surgical repair and endovascular aneurysm repair.
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Affiliation(s)
- Chung Won Lee
- Department of Thoracic and Cardiovascular Surgery, Pusan National University School of Medicine
| | - Miju Bae
- Department of Thoracic and Cardiovascular Surgery, Pusan National University School of Medicine
| | - Sung Woon Chung
- Department of Thoracic and Cardiovascular Surgery, Pusan National University School of Medicine
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Morbimortalidad de los aneurismas de aorta abdominal rotos durante la implantación del tratamiento endovascular en nuestro centro. ANGIOLOGIA 2015. [DOI: 10.1016/j.angio.2014.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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van Beek S, Reimerink J, Vahl A, Wisselink W, Peters R, Legemate D, Balm R. Editor's Choice - External Validation of Models Predicting Survival After Ruptured Abdominal Aortic Aneurysm Repair. Eur J Vasc Endovasc Surg 2015; 49:10-6. [DOI: 10.1016/j.ejvs.2014.10.012] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Accepted: 10/11/2014] [Indexed: 11/26/2022]
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Ozen A, Unal EU, Kubat E, Turkcan BS, Caliskan A, Aytekin B, Aksoyek A, Birincioglu CL, Pac M. Glasgow aneurysm scores in patients undergoing open surgical procedure for aortic aneurysm. Vascular 2014; 23:277-80. [PMID: 25183698 DOI: 10.1177/1708538114548263] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND To assess the applicability of the Glasgow aneurysm score (GAS) in patients with aortic aneurysm undergoing an elective open surgical procedure in our hospital. MATERIALS AND METHODS A total of 105 patients undergoing elective open surgical procedure between January 2006 and June 2012 were evaluated retrospectively. Glasgow aneurysm score (GAS) was calculated as age+7 points for myocardial disease, +10 points for cerebrovascular disease, and +14 points for renal disease. The best cut-off value for GAS was determined using the ROC curve analysis. RESULTS The hospital mortality rate was 3.8% (4 patients). GAS was significantly lower in patients who survived the operation (76.05 ± 14.71 vs. 92.0 ± 10.8 respectively, p = 0.031). The ICU stay was also significantly lower in patients who survived the operation (2.37 ± 5.23) compared to the nonsurvivors (25.67 ± 13.80, p = 0.001). No significant difference was observed regarding age, duration of hospital stay, and aortic diameter. The area under the ROC curve was 0.818 and for a 100% sensitivity rate, the cut-off value for GAS was 77.5 with a 58.4% specificity rate (p = 0.031). All patients with a GAS < 77.5 were alive after surgery. CONCLUSION The GAS appears to be a reliable clinical predictor for in hospital mortality following elective repair of abdominal aortic aneurysm following open surgical procedure.
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Affiliation(s)
- Anil Ozen
- Department of Cardiovascular Surgery, Turkey Yuksek Ihtisas Training and Research Hospital, Ankara, Turkey
| | - Ertekin Utku Unal
- Department of Cardiovascular Surgery, Turkey Yuksek Ihtisas Training and Research Hospital, Ankara, Turkey
| | - Emre Kubat
- Department of Cardiovascular Surgery, Turkey Yuksek Ihtisas Training and Research Hospital, Ankara, Turkey
| | - Basak Soran Turkcan
- Department of Cardiovascular Surgery, Turkey Yuksek Ihtisas Training and Research Hospital, Ankara, Turkey
| | - Aytac Caliskan
- Department of Cardiovascular Surgery, Turkey Yuksek Ihtisas Training and Research Hospital, Ankara, Turkey
| | - Bahadir Aytekin
- Department of Cardiovascular Surgery, Turkey Yuksek Ihtisas Training and Research Hospital, Ankara, Turkey
| | - Aysen Aksoyek
- Department of Cardiovascular Surgery, Turkey Yuksek Ihtisas Training and Research Hospital, Ankara, Turkey
| | - Cemal Levent Birincioglu
- Department of Cardiovascular Surgery, Turkey Yuksek Ihtisas Training and Research Hospital, Ankara, Turkey
| | - Mustafa Pac
- Department of Cardiovascular Surgery, Turkey Yuksek Ihtisas Training and Research Hospital, Ankara, Turkey
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Antonopoulos CN, Kakisis JD, Andrikopoulos V, Dervisis K, Georgopoulos S, Giannoukas A, Kiskinis D, Machairas A, Papavassiliou V, Liapis CD, Antoniadis P, Bessias N, Giannakopoulos TG, Kaperonis E, Klonaris C, Saleptsis V, Saratzis N, Seretis K, Tampakis C. Predictors Affecting In-hospital Mortality of Ruptured Abdominal Aortic Aneurysms: A Greek Multicenter Study. Ann Vasc Surg 2014; 28:1384-90. [DOI: 10.1016/j.avsg.2013.12.028] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2013] [Revised: 11/20/2013] [Accepted: 12/29/2013] [Indexed: 12/20/2022]
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van Beek SC, Legemate DA, Vahl A, Bouman CSC, Vogt L, Wisselink W, Balm R. Acute kidney injury defined according to the 'Risk,' 'Injury,' 'Failure,' 'Loss,' and 'End-stage' (RIFLE) criteria after repair for a ruptured abdominal aortic aneurysm. J Vasc Surg 2014; 60:1159-1167.e1. [PMID: 24998838 DOI: 10.1016/j.jvs.2014.04.072] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Accepted: 04/29/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Acute kidney injury (AKI) is a serious complication after repair of a ruptured abdominal aortic aneurysm (RAAA). In the present Society for Vascular Surgery (SVS)/International Society for CardioVascular Surgery (ISCVS) reporting standards patients are classified as no dialysis (grade I), as temporary dialysis (grade II), and as permanent dialysis or fatal outcome (grade III). However, AKI is a broad clinical syndrome including more than the requirement for renal replacement therapy. The recently introduced 'Risk,' 'Injury,' 'Failure,' 'Loss,' and 'End-stage' (RIFLE) classification for AKI comprises three severity categories based on serum creatinine and urine output ('Risk,' 'Injury,' and 'Failure'). The objective of the present study was to assess the incidence of AKI using the RIFLE criteria (AKIRIFLE). Secondary objectives were to assess the incidence of AKI as defined using the SVS/ISCVS reporting standards (AKISVS/ISCVS) and the association between AKIRIFLE and death. METHODS This was an observational cohort study in 362 consecutive patients with an RAAA in three hospitals in Amsterdam (The Netherlands) between 2004 and 2011. The end points were the incidence of AKIRIFLE, of AKISVS/ISCVS, and the combined 30-day or in-hospital death rate. A multivariable logistic regression model was made to assess the association between AKIRIFLE and death after adjustment for preoperative shock profile (Glasgow Aneurysm Score) and postoperative shock profile (Acute Physiology and Chronic Health Evaluation [APACHE] II score, use of vasopressors, and fluid balance during the first 24 hours after intervention). RESULTS AKIRIFLE occurred in 74% (267/362; 95% confidence interval [CI], 69%-78%), with 27% of these patients categorized as 'Risk' (71/267; 95% CI, 22%-32%), 39% categorized as 'Injury' (104/267, 95% CI, 33%-45%), and 34% categorized as 'Failure' (92/267; 95% CI, 29%-40%). AKISVS/ISCVS occurred in 48% (175/362; 95% CI, 43%-53%), with 53% of these categorized as 'grade I' (92/175; 95% CI, 45%-60%), 19% as 'grade II' (34/175; 95% CI, 14%-26%), and 28% as 'grade III' (49/175; 95% CI, 22%-35%). After multivariable adjustment for shock profiles the risk of dying in patients categorized as AKIRIFLE 'Failure' was greater than in patients without AKIRIFLE (adjusted odds ratio, 6.360; 95% CI, 2.231-18.130). CONCLUSIONS The incidence of AKI defined according to the RIFLE criteria (74%) was greater than defined using the SVS/ISCVS reporting standards (48%) and patients categorized as 'Failure' using the RIFLE criteria had a greater risk of dying than patients without AKI. These results indicate that the problem of AKI is much bigger than previously anticipated and that minimizing injury to the kidney could be an important focus of future research on reducing the death rate after RAAA repair.
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Affiliation(s)
- Sytse C van Beek
- Department of Vascular Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Dink A Legemate
- Department of Vascular Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Anco Vahl
- Department of Vascular Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Catherine S C Bouman
- Department of Intensive Care, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Liffert Vogt
- Department of Internal Medicine, Section of Nephrology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Willem Wisselink
- Department of Vascular Surgery, VU University Medical Centre, Amsterdam, The Netherlands
| | - Ron Balm
- Department of Vascular Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
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Özen A, Unal EU, Mola S, Erkengel I, Kiris E, Aksöyek A, Saritas A, Birincioğlu CL. Glasgow aneurysm score in predicting outcome after ruptured abdominal aortic aneurysm. Vascular 2014; 23:120-3. [PMID: 24841850 DOI: 10.1177/1708538114533539] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To assess the ability of Glasgow Aneurysm Score in predicting postoperative mortality for ruptured aortic aneurysm which may assist in decision making regarding the open surgical repair of an individual patient. METHODS A total of 121 patients diagnosed of ruptured abdominal aortic aneurysm who underwent open surgery in our hospital between 1999 and 2013 were included. The Glasgow Aneurysm Score for each patient was graded according to the Glasgow Aneurysm Score (Glasgow Aneurysm Score = age in years + 17 for shock + 7 for myocardial disease + 10 for cerebrovascular disease + 14 for renal disease). The groups were divided as Group 1 (containing the patients who died) and Group 2 (the patients who were discharged). The Glasgow Aneurysm Scores amongst the groups were compared. RESULTS Out of 121 patients, 108 (89.3%) were males and 13 (10.7%) were females. The in-hospital mortality was 48 patients (39.7%). The Glasgow Aneurysm Score was 84.15 ± 15.94 in Group 1 and 75.14 ± 14.67 in Group 2 which revealed significance (p = 0.002). The most appropriate cut-off value for Glasgow Aneurysm Score was determined as 78.5 (AUC = 0.669, p = 0.002, sensitivity: 64.6%, specificity: 60.3%). Glasgow Aneurysm Score value above 78.5 is associated with almost threefold increase in mortality (p = 0.007, OR:2.76, 95% CI 1.30-5.89). In further logistic regression models, Glasgow Aneurysm Score value and preoperative hematocrit values were found to be independent predictors for mortality (p = 0.023 and p = 0.007, respectively). CONCLUSION Glasgow Aneurysm Score may have a predictive value for outcome of patients with ruptured abdominal aortic aneurysm undergoing open surgical procedure and it appears to be a useful tool in clinical decision-making of an individual patient when integrated with clinical experience.
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Affiliation(s)
- Anıl Özen
- Türkiye Yüksek İhtisas Hospital, Cardiovascular Surgery Clinic, Ankara, Turkey
| | - Ertekin Utku Unal
- Türkiye Yüksek İhtisas Hospital, Cardiovascular Surgery Clinic, Ankara, Turkey
| | - Serkan Mola
- Türkiye Yüksek İhtisas Hospital, Cardiovascular Surgery Clinic, Ankara, Turkey
| | - Ibrahim Erkengel
- Türkiye Yüksek İhtisas Hospital, Cardiovascular Surgery Clinic, Ankara, Turkey
| | - Erman Kiris
- Türkiye Yüksek İhtisas Hospital, Cardiovascular Surgery Clinic, Ankara, Turkey
| | - Aysen Aksöyek
- Türkiye Yüksek İhtisas Hospital, Cardiovascular Surgery Clinic, Ankara, Turkey
| | - Ahmet Saritas
- Türkiye Yüksek İhtisas Hospital, Cardiovascular Surgery Clinic, Ankara, Turkey
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Open versus Endovascular Repair of Abdominal Aortic Aneurysm in the Elective and Emergent Setting in a Pooled Population of 37,781 Patients: A Systematic Review and Meta-Analysis. ISRN CARDIOLOGY 2014; 2014:149243. [PMID: 25006502 PMCID: PMC4004021 DOI: 10.1155/2014/149243] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Accepted: 02/03/2014] [Indexed: 01/09/2023]
Abstract
Background. We evaluated the incidence of mortality and myocardial infarction (MI) in endovascular repair (EVAR) as compared to open aneurysm repair (OAR) in both elective and ruptured abdominal aortic aneurysm (AAA ) setting. Methods. We analyzed the rates of 30-day mortality, 30-day MI, and hospital length of stay (LOS) based on comparative observation and randomized control trials involving EVAR and OAR. Results. 41 trials compared EVAR to OAR with a total pooled population of 37,781 patients. Analysis of elective and ruptured AAA repair favored EVAR with respect to 30-day mortality with a pooled odds ratio of 0.19 (95% CI 0.17–0.20; I2 = 88.9%; P < 0.001). There were a total of 1,835 30-day MI events reported in the EVAR group as compared to 2,483 events in the OAR group. The pooled odds ratio for elective AAA was 0.74 (95% CI 0.58–0.96; P = 0.02) in favor of EVAR. The average LOS was reduced by 296.75 hrs (95% CI 156.68–436.82 hrs; P < 0.001) in the EVAR population. Conclusions. EVAR has lower rates of 30-day mortality, 30-day MI, and LOS in both elective and ruptured AAA repair.
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Karthikesalingam A, Holt PJ, Vidal-Diez A, Ozdemir BA, Poloniecki JD, Hinchliffe RJ, Thompson MM. Mortality from ruptured abdominal aortic aneurysms: clinical lessons from a comparison of outcomes in England and the USA. Lancet 2014; 383:963-9. [PMID: 24629298 DOI: 10.1016/s0140-6736(14)60109-4] [Citation(s) in RCA: 220] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The outcome of patients with ruptured abdominal aortic aneurysm (rAAA) varies by country. Study of practice differences might allow the formulation of pathways to improve care. METHODS We compared data from the Hospital Episode Statistics for England and the Nationwide Inpatient Sample for the USA for patients admitted to hospital with rAAA from 2005 to 2010. Primary outcomes were in-hospital mortality, mortality after intervention, and decision to follow non-corrective treatment. In-hospital mortality and the rate of non-corrective treatment were analysed by binary logistic regression for each health-care system, after adjustment for age, sex, year, and Charlson comorbidity index. FINDINGS The study included 11,799 patients with rAAA in England and 23,838 patients with rAAA in the USA. In-hospital mortality was lower in the USA than in England (53·05% [95% CI 51·26-54·85] vs 65·90%; p<0·0001). Intervention (open or endovascular repair) was offered to a greater proportion of cases in the USA than in England (19,174 [80·43%] vs 6897 [58·45%]; p<0·0001) and endovascular repair was more common in the USA than in England (4003 [20·88%] vs 589 [8·54%]; p<0·0001). Postintervention mortality was similar in both countries (41·77% for England and 41·65% for USA). These observations persisted in age-matched and sex-matched comparisons. In both countries, reduced mortality was associated with increased use of endovascular repair, increased hospital caseload (volume) for rAAA, high hospital bed capacity, hospitals with teaching status, and admission on a weekday. INTERPRETATION In-hospital survival from rAAA, intervention rates, and uptake of endovascular repair are lower in England than in the USA. In England and the USA, the lowest mortality for rAAA was seen in teaching hospitals with larger bed capacities and doing a greater proportion of cases with endovascular repair. These common factors suggest strategies for improving outcomes for patients with rAAA. FUNDING None.
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Affiliation(s)
| | - Peter J Holt
- St George's Vascular Institute, St George's, University of London, London, UK.
| | - Alberto Vidal-Diez
- St George's Vascular Institute, St George's, University of London, London, UK
| | - Baris A Ozdemir
- St George's Vascular Institute, St George's, University of London, London, UK
| | - Jan D Poloniecki
- St George's Vascular Institute, St George's, University of London, London, UK
| | - Robert J Hinchliffe
- St George's Vascular Institute, St George's, University of London, London, UK
| | - Matthew M Thompson
- St George's Vascular Institute, St George's, University of London, London, UK
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Emergent endovascular vs. open surgery repair for ruptured abdominal aortic aneurysms: a meta-analysis. PLoS One 2014; 9:e87465. [PMID: 24498112 PMCID: PMC3909181 DOI: 10.1371/journal.pone.0087465] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Accepted: 12/27/2013] [Indexed: 12/13/2022] Open
Abstract
Objectives To systematically review studies comparing peri-operative mortality and length of hospital stay in patients with ruptured abdominal aortic aneurysms (rAAAs) who underwent endovascular aneurysm repair (EVAR) to patients who underwent open surgical repair (OSR). Methods The Medline, Cochrane, EMBASE, and Google Scholar databases were searched until Apr 30, 2013 using keywords such as abdominal aortic aneurysm, emergent, emergency, rupture, leaking, acute, endovascular, stent, graft, and endoscopic. The primary outcome was peri-operative mortality and the secondary outcome was length of hospital stay. Results A total of 18 studies (2 randomized controlled trials, 5 prospective studies, and 11 retrospective studies) with a total of 135,734 rAAA patients were included. rAAA patients who underwent EVAR had significantly lower peri-operative mortality compared to those who underwent OSR (overall OR = 0.62, 95% CI = 0.58 to 0.67, P<0.001). rAAA patients with EVAR also had a significantly shorter mean length of hospital stay compared to those with OSR (difference in mean length of stay ranged from −2.00 to −19.10 days, with the overall estimate being −5.25 days (95% CI = −9.23 to −1.26, P = 0.010). There was no publication bias and sensitivity analysis showed good reliability. Conclusions EVAR confers significant benefits in terms of peri-operative mortality and length of hospital stay. There is a need for more randomized controlled trials to compare outcomes of EVAR and OSR for rAAA.
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Antoniou GA, Georgiadis GS, Antoniou SA, Pavlidis P, Maras D, Sfyroeras GS, Georgakarakos EI, Lazarides MK. Endovascular repair for ruptured abdominal aortic aneurysm confers an early survival benefit over open repair. J Vasc Surg 2013; 58:1091-105. [DOI: 10.1016/j.jvs.2013.07.109] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Revised: 07/16/2013] [Accepted: 07/26/2013] [Indexed: 01/08/2023]
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Deanda A, Cayne NS. Acute aortic syndromes. Hosp Pract (1995) 2013; 41:34-44. [PMID: 23568173 DOI: 10.3810/hp.2013.04.1024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Acute aortic syndrome is a term that describes one of a number of different pathologic entities. Each of these conditions requires urgent or emergent evaluation and may possibly require surgical intervention. However, both entities may be unfamiliar to the nonsurgical (and in some cases, surgical) practitioner and they may mimic more common diseases or be missed entirely. An understanding of the processes, nomenclature, and management options is critical in optimizing patient care.
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Affiliation(s)
- Abe Deanda
- Department of Cardiothoracic Surgery, New York University-Langone Medical Center, New York, NY 10016, USA.
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Takagi H, Umemoto T. A Meta-Analysis of Randomized and Risk-Adjusted Observational Studies of Endovascular Versus Open Repair for Ruptured Abdominal Aortic Aneurysm. Vasc Endovascular Surg 2012; 45:717-9. [DOI: 10.1177/1538574411418010] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Hisato Takagi
- Department of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan
| | - Takuya Umemoto
- Department of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan
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Evaluation of the perioperative risk factors in patients with the abdominal aorta aneurysm--literature review. POLISH JOURNAL OF SURGERY 2011; 83:571-8. [PMID: 22189286 DOI: 10.2478/v10035-011-0091-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Abstract
Ruptured abdominal aorta aneurysm (rAAA) is the 13th leading cause of death in the United States. Despite many advances in the field of vascular surgery, the improvement in mortality rates of rAAA have been very modest. Although endovascular repair has surpassed open repair for elective AAA repair in the United States, open rAAA repair remains the most common therapy for this devastating vascular emergency. In this article, we discuss open surgical management for rAAA. We also describe a fast-track algorithm we have developed at the University of Massachusetts where open and endovascular repairs play equally important roles in management of rAAA.
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Affiliation(s)
- Mohammad H Eslami
- Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, 55 Lake Avenue, North Worcester, MA 01655, USA.
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Jonker FH, Verhagen HJ, Lin PH, Heijmen RH, Trimarchi S, Lee WA, Moll FL, Atamneh H, Rampoldi V, Muhs BE. Open surgery versus endovascular repair of ruptured thoracic aortic aneurysms. J Vasc Surg 2011; 53:1210-6. [DOI: 10.1016/j.jvs.2010.10.135] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2010] [Revised: 10/27/2010] [Accepted: 10/31/2010] [Indexed: 11/30/2022]
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Diagnostic accuracy and receiver-operating characteristics curve analysis in surgical research and decision making. Ann Surg 2011; 253:27-34. [PMID: 21294285 DOI: 10.1097/sla.0b013e318204a892] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
In surgical research, the ability to correctly classify one type of condition or specific outcome from another is of great importance for variables influencing clinical decision making. Receiver-operating characteristic (ROC) curve analysis is a useful tool in assessing the diagnostic accuracy of any variable with a continuous spectrum of results. In order to rule a disease state in or out with a given test, the test results are usually binary, with arbitrarily chosen cut-offs for defining disease versus health, or for grading of disease severity. In the postgenomic era, the translation from bench-to-bedside of biomarkers in various tissues and body fluids requires appropriate tools for analysis. In contrast to predetermining a cut-off value to define disease, the advantages of applying ROC analysis include the ability to test diagnostic accuracy across the entire range of variable scores and test outcomes. In addition, ROC analysis can easily examine visual and statistical comparisons across tests or scores. ROC is also favored because it is thought to be independent from the prevalence of the condition under investigation. ROC analysis is used in various surgical settings and across disciplines, including cancer research, biomarker assessment, imaging evaluation, and assessment of risk scores.With appropriate use, ROC curves may help identify the most appropriate cutoff value for clinical and surgical decision making and avoid confounding effects seen with subjective ratings. ROC curve results should always be put in perspective, because a good classifier does not guarantee the expected clinical outcome. In this review, we discuss the fundamental roles, suggested presentation, potential biases, and interpretation of ROC analysis in surgical research.
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Jonker FHW, Verhagen HJM, Mojibian H, Davis KA, Moll FL, Muhs BE. Aortic endograft sizing in trauma patients with hemodynamic instability. J Vasc Surg 2010; 52:39-44. [PMID: 20494542 DOI: 10.1016/j.jvs.2010.02.256] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2009] [Revised: 02/01/2010] [Accepted: 02/19/2010] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To investigate changes in aortic diameter in hemodynamically unstable trauma patients and the implications for sizing of thoracic endovascular aortic repair (TEVAR) in patients with traumatic thoracic aortic injury (TTAI). METHODS We retrospectively evaluated all trauma patients that were admitted with hemodynamic instability (mean arterial pressure <95 mm Hg and a pulse >or=100 beats/min) and underwent computed tomography (CT) of the thorax and abdomen both at admission and at another moment (control CT scan), at the Yale New Haven Hospital between 2002 and 2009. The CT examinations were reviewed in a blinded fashion and the aortic diameter was measured at six different levels by a cardiovascular radiologist. Differences in aortic diameter between the initial CTs obtained in the trauma bay and the control CTs were compared using the paired Student t test. RESULTS Forty-three patients were identified, including 32 males. Mean age was 37 +/- 16 years, mean injury severity score was 26 +/- 15, the mean pulse and blood pressure were 122 beats/min and 103/63 mm Hg, respectively. Overall, the mean aortic diameter was significantly larger at the control CT examinations compared with the initial CT examinations while hemodynamically unstable, at all evaluated levels. Among patients with a pulse >or=130/min, the mean increase in aortic diameter was most consistent at the level of the mid descending thoracic aorta (DTA, +12.6%, P = .003) and at the level of the infrarenal aorta (+12.6%, P = .004). CONCLUSIONS The aortic diameter decreases dramatically in trauma patients with hemodynamic instability. This decrease in aortic diameter could theoretically lead to inaccurate aortic measurements and undersizing of the endograft in hemodynamically unstable TTAI patients requiring TEVAR. Further research is needed to better predict the actual aortic diameters in individual hemodynamically unstable patients requiring endovascular aortic repair.
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Affiliation(s)
- Frederik H W Jonker
- Sections of Vascular Surgery, Interventional Radiology, and Trauma, Surgical Critical Care and Surgical Emergencies, Yale University School of Medicine, New Haven, CT 06510, USA
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Regarding "Prediction of 30-day mortality after endovascular repair or open surgery in patients with ruptured abdominal aortic aneurysms". J Vasc Surg 2009; 50:1246; author reply 1246. [PMID: 19878798 DOI: 10.1016/j.jvs.2009.06.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2009] [Revised: 06/16/2009] [Accepted: 06/17/2009] [Indexed: 11/23/2022]
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